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A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
- A. “You’ll need more insulin when you exercise or increase your food intake.”
- B. “You’ll need less insulin when you exercise or reduce your food intake.”
- C. “You’ll need less insulin when you increase your intake.”
- D. “You’ll need more insulin when you exercise or decrease your food intake.”
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage. Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.
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Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Bowel management
- C. Sexual activity
- D. . All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.
Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.
Autoimmunity is defined as a phenomenon involving which of the following?
- A. Production of endotoxins that destroy B
- B. Overproduction of reagin antibody
- C. Depression of the immune response
- D. Inability to differentiate self from nonself
Correct Answer: D
Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection.
Summary:
A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure.
C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention.
D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.
Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
- A. cover wound with moist sterile dressing
- B. find out how this happened
- C. place sterile dry gauze on the wound
- D. pour sterile water into the wound
Correct Answer: A
Rationale: Correct Answer: A: Cover wound with moist sterile dressing
Rationale:
1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing.
2. Moist dressing prevents the wound from drying out and minimizes the risk of infection.
3. The moist environment supports healing by promoting cell growth and preventing tissue damage.
4. It protects the exposed bowel from further injury and contamination.
Summary:
B: Finding out how this happened is important but not an immediate priority for patient care.
C: Placing sterile dry gauze can lead to the wound drying out and hinder healing.
D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.