Nokea
A client has recently been diagnosed with Type 1 diabetes mellitus. The nurse is instructing the client about self-administering insulin. What should be included in the teaching? Select all that apply.
- A. Pinch the muscle and inject the needle at a 45-degree angle.
- B. Shake the vial of insulin before drawing it up.
- C. When using the abdominal site, inject at least 1 inch from the umbilicus.
- D. When mixing insulins, draw up the regular insulin before the NPH.
- E. Do a finger stick glucose test before administering insulin.
- F. Use one site per day for insulin injections.
Correct Answer: C,D,E
Rationale: Injecting 1 inch from the umbilicus ensures absorption, drawing regular insulin before NPH prevents contamination, and checking glucose confirms dosing need. Pinch skin (not muscle), don't shake insulin, and rotate sites.
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The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
- A. Chronic vessel plaque formation
- B. Pulmonary embolism
- C. Occlusions at the vessel bifurcations
- D. Coronary artery aneurysms
Correct Answer: D
Rationale: Coronary artery aneurysms. Kawasaki disease can lead to inflammation and aneurysms in coronary arteries.
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get the provider's discharge order.
- E. Cbe released because you are still suicidal.
- F. You can be released only if you sign a no suicide contract.
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
- A. Increase fluid intake to prevent dehydration
- B. Place client on a pressure reducing support surface
- C. Use skin care products designed for use with incontinence
- D. Increase caloric intake to aid healing
Correct Answer: B
Rationale: Place client on a pressure reducing support surface. This prevents skin breakdown due to immobility and reduced sensation.
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds