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A client with diabetes begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.
- B. We can teach your daughter to give the shots so you will not have to do it.
- C. I can arrange to have a home care nurse give you the shots every day.
- D. What is it about giving yourself the insulin shots that bothers you?
Correct Answer: D
Rationale: The correct response is option D because it is an open-ended question that allows the client to express their feelings and concerns. This approach facilitates a therapeutic communication process by encouraging the client to verbalize their thoughts, emotions, and fears related to giving themselves insulin shots. Option A is incorrect as it uses a fear-inducing statement that may not be helpful in addressing the client's emotional needs. Option B assumes involvement of a family member without exploring the client's feelings further. Option C offers a solution without addressing the client's underlying concerns and emotions, potentially overlooking essential aspects of client-centered care.
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The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?
- A. I will take my medication only when I have chest pain.
- B. I will follow a heart-healthy diet and exercise regularly.
- C. I will avoid smoking and limit alcohol intake.
- D. I will contact my doctor if I experience chest pain or shortness of breath.
Correct Answer: A
Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.
Which client is at greatest risk for coronary artery disease?
- A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
- B. A 43-year-old male with a family history of CAD and a cholesterol level of 158 (8.8 mmol/L).
- C. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin.
- D. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).
Correct Answer: D
Rationale: The 65-year-old female who is obese with a high LDL level of 188 (10.4 mmol/L) is at the greatest risk for coronary artery disease. Obesity and high LDL cholesterol levels are significant risk factors for developing coronary artery disease. While factors like mitral valve prolapse (choice A) and a family history of CAD (choice B) can contribute to the risk, they are not as significant as obesity and high LDL levels. Choice C, a 56-year-old male with high HDL and taking atorvastatin, is actually at lower risk due to the high HDL levels and being on statin therapy, which helps reduce cholesterol levels and lower the risk of coronary artery disease.
A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?
- A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.
- B. The triglycerides are elevated and will not return to normal without these medications.
- C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed.
- D. These medications will reduce the risk of type 2 diabetes.
Correct Answer: C
Rationale: CRP is a marker of inflammation, which is elevated in cardiovascular disease. Statins and aspirin help lower CRP and reduce the risk of heart attacks and strokes.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a high-fiber diet and increase fluid intake.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a bland diet and avoid spicy foods.
- D. Eat a soft diet with increased intake of milk and milk products.
Correct Answer: A
Rationale: A high-fiber diet with increased fluid intake is the most appropriate diet instruction for a client diagnosed with diverticulosis. High-fiber foods help prevent constipation and promote bowel regularity, reducing the risk of complications such as diverticulitis. Adequate fluid intake is crucial to soften stool and aid in digestion. Choice B, having small frequent meals and sitting up after meals, may be beneficial for some gastrointestinal conditions but is not specific to diverticulosis. Choice C, eating a bland diet and avoiding spicy foods, is not necessary for diverticulosis management. Choice D, consuming a soft diet with increased milk and milk products, may worsen symptoms in diverticulosis due to the potential for increased gas production and bloating.
When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct Answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.