Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?

Correct Answer: C

Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.

Correct Answer: D

Rationale: A herniated nucleus pulposus at the C4-C5 and C5-C6 interspace typically results in neck and shoulder pain, which can radiate to the scapular region. The herniation at these levels can cause irritation or compression of the cervical nerve roots leading to pain, numbness, tingling, or weakness in the affected areas. Constant, throbbing headaches are not typically associated with this specific diagnosis. Clonus in the lower extremities and numbness of the face are also not common findings related to herniated nucleus pulposus at the cervical spine levels mentioned.

Correct Answer: A

Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.

Correct Answer: B

Rationale: The correct administration time frame for a dose of parenteral ampicillin after it has been mixed is within 4 hours. This is based on the stability and compatibility of ampicillin when it is mixed and prepared for injection. Beyond 4 hours, the effectiveness and safety of the medication may be compromised due to potential degradation or contamination. It is crucial for healthcare providers to adhere to the recommended administration time frame to ensure the patient receives the full therapeutic benefits of the medication and to prevent any negative outcomes associated with the degradation of the drug.

Correct Answer: D

Rationale: The correct assessment findings to stay alert for when evaluating for hypothyroidism are decreased body temperature and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a decrease in metabolic rate. This can result in symptoms such as feeling cold all the time and a lower body temperature. Therefore, the nurse should keep an eye out for these symptoms during the assessment of a client being evaluated for hypothyroidism. Symptoms such as exophthalmos and conjunctival redness are more commonly associated with hyperthyroidism.