Nokea
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.
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Which of the ff blood vessel is commonly affected by thrombophlebitis?
- A. Veins deep in the upper extremities
- B. Popliteal vein of the leg
- C. Veins deep in the lower extremities
- D. Veins connected to the heart
Correct Answer: C
Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (A) are less commonly affected. The popliteal vein of the leg (B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (D) are arteries, not veins, and are not typically involved in thrombophlebitis.
A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?
- A. “I can travel to Florida and sunbathe all day.”
- B. “Now I can eat whatever I want, whenever I want.”
- C. “I’ll take my medication in the morning, every morning.”
- D. “I won’t need medication once my pressure goes down.”
Correct Answer: C
Rationale: The correct answer is C: “I’ll take my medication in the morning, every morning.” This statement reflects understanding of the treatment regimen by indicating consistency in taking bumetanide for hypertension control. Taking the medication as prescribed is crucial for its effectiveness in managing blood pressure.
Choice A is incorrect because sunbathing all day may not be advisable, especially if the patient is on medication. Choice B is incorrect as it implies no consideration for dietary restrictions that may be necessary with the medication. Choice D is incorrect as stopping medication once blood pressure decreases is not recommended and can lead to rebound hypertension.
While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
- A. It promotes the clients compliance with therapy
- B. It minimizes the chances of adverse effects
- C. It promotes a strict food and fluid intake habit
- D. It raises the self esteem of the client
Correct Answer: A
Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan.
Step 2: Understanding leads to better compliance with therapy recommendations.
Step 3: Compliance improves outcomes and prevents complications.
Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.
Which white blood cells are involved in releasing histamine during an allergic reaction?
- A. Basophils
- B. Monocytes
- C. Eosinophils
- D. Neutrophils
Correct Answer: A
Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Squeeze the nipple to check for drainage
- C. Check the area after the next menstrual period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.
Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.