Nokea
A client has a scheduled office visit due to a new diagnosis of diabetes mellitus. The client tells the nurse that he has trouble maintaining proper health due to anxiety regarding the self-administration of insulin. Which teaching/learning strategy should the nurse initially plan to implement?
- A. Teach a family member to give the client the insulin.
- B. Leave a list of instructions at the bedside for practicing the insulin injections.
- C. Insert the needle, and have the client push in the plunger and remove the needle.
- D. Give the injection until the client feels sufficiently confident to preform it alone.
Correct Answer: C
Rationale: Some clients find it difficult to insert a needle into their own skin. For these clients, the nurse might assist by selecting the site and inserting the needle. Then, as a first step in self-injection, the client can push in the plunger and remove the needle. The remaining options place the client in a dependent role.
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The nurse is caring for a teenage client diagnosed with anorexia nervosa. The client's mother asks the nurse about eating disorders in general. Which information would the nurse provide? Select all that apply.
- A. Anorexia nervosa is more common than bulimia.
- B. Clients with bulimia may have erosion of the tooth enamel.
- C. Binging and purging can occur in both anorexia nervosa and bulimia.
- D. Extreme exercising and calorie restriction is common with anorexia nervosa.
- E. Clients with eating disorders may develop the disorders because of issues of power and control.
- F. Clients with anorexia have a distorted body image and think that they are fat even if they are very thin.
Correct Answer: B,C,D,E,F
Rationale: Bulimia is more common than anorexia, making A incorrect. Tooth enamel erosion, binging/purging, extreme exercising, power/control issues, and distorted body image are all accurate.
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
- A. The financial status of the client
- B. Postoperative communication techniques
- C. Information given to the client by the surgeon
- D. The client's support systems and coping behaviors
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client?
- A. Grief
- B. Socialization issues
- C. Issues related to sensory perception
- D. Trouble with coping with a disease process
Correct Answer: D
Rationale: A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.
An older client is brought to the emergency department by a family member with whom the client lives. The nurse observes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. Based on the nurse's assessment data, the client is suspected of which form of victimization?
- A. Sexual abuse
- B. Physical abuse
- C. Emotional abuse
- D. Psychological abuse
Correct Answer: B
Rationale: Victimization in a family can take many forms. When analyzing a specific client situation, it is important to understand which form of abuse is being considered. Physical abuse can take the form of battering (hitting, slapping, striking), or it can be more subtle, such as neglect (the failure to meet basic needs). Sexual abuse can involve unwanted sexual remarks, sexual advances, and physical sexual acts. Emotional and psychological abuse can involve inflicting verbal statements that cause mental anguish or alienation of the victim.