Nokea
A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
- B. “Rotate injection sites within the same anatomic region, not among different regions.”
- C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
- D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
Correct Answer: B
Rationale: The correct answer is B: “Rotate injection sites within the same anatomic region, not among different regions.” This instruction is important to prevent lipodystrophy and ensure consistent insulin absorption. Rotating sites within the same region helps maintain consistent insulin absorption rates and reduces the risk of developing scar tissue or fatty deposits. Injecting into healthy tissue with large blood vessels and nerves (choice A) can lead to inconsistent absorption. Administering insulin into areas of scar tissue or hypotrophy (choice C) can also disrupt absorption. Injecting into sites above muscles planned for exercise (choice D) can lead to unpredictable insulin absorption. Rotation within the same region optimizes insulin delivery and prevents complications.
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The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for Parkinson's disease as it is converted to dopamine in the brain, replenishing dopamine levels which are depleted in Parkinson's. Selegiline and Symmetrel provide symptomatic relief but are not as effective as Levodopa. Permax is not commonly used due to its association with serious side effects like heart valve damage.
In an individual with Sjogren’s syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.
Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term.
Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues.
Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels.
Step 4: Emergency numbers are important but secondary to long-term management.
Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.
The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has two young children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
- A. Tell the client’s spouse or partner to be supportive while she recovers.
- B. Encourage the client to proceed with the next phase of treatment.
- C. Recommend that the client remain cheerful for the sake of her children.
- D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
Correct Answer: D
Rationale: The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time.
A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone.
B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide.
C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.