Nokea
A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?
- A. Walk barefoot whenever possible to toughen your feet.
- B. Soak your feet in hot water daily to improve circulation.
- C. Trim your toenails straight across to prevent ingrown toenails.
- D. Use a heating pad to keep your feet warm.
Correct Answer: C
Rationale: Correct Answer: C - Trim your toenails straight across to prevent ingrown toenails.
Rationale:
1. Trimming toenails straight across helps prevent ingrown nails.
2. Ingrown nails can lead to infection, especially risky for diabetics due to poor wound healing.
3. Walking barefoot toughens feet, increasing risk of injury.
4. Soaking in hot water can cause burns or skin damage.
5. Using a heating pad can lead to burns or decreased sensation in feet, increasing injury risk.
Summary:
Option C is correct as it directly addresses a common issue in diabetic foot care - ingrown toenails. Options A, B, and D pose risks of injury or damage to the feet, which is detrimental for diabetic individuals.
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A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?
- A. Serum glucose of 350 mg/dL.
- B. Serum potassium of 2.8 mEq/L.
- C. Serum sodium of 136 mEq/L.
- D. Serum bicarbonate of 20 mEq/L.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 2.8 mEq/L. Hypokalemia can lead to life-threatening cardiac arrhythmias, especially in diabetic patients with hyperglycemia. Immediate intervention is needed to prevent cardiac complications.
A: Serum glucose of 350 mg/dL is high but not immediately life-threatening.
C: Serum sodium of 136 mEq/L is within normal range and does not require immediate intervention.
D: Serum bicarbonate of 20 mEq/L is slightly low but does not pose an immediate risk to the patient's life.
When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.
The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?
- A. Thickened and hardened skin.
- B. Painless ulcers on the fingertips.
- C. Episodes of cyanosis and pallor in the fingers.
- D. Red, scaly patches on the hands.
Correct Answer: C
Rationale: The correct answer is C: Episodes of cyanosis and pallor in the fingers. Raynaud's phenomenon is characterized by vasospasms of small arteries, leading to reduced blood flow and color changes in the digits. Cyanosis (bluish discoloration) and pallor (pale color) are common during episodes. Thickened and hardened skin (A) is associated with scleroderma. Painless ulcers on the fingertips (B) are seen in advanced stages of systemic sclerosis. Red, scaly patches on the hands (D) are indicative of psoriasis, not Raynaud's phenomenon.
The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?
- A. Flush the NG tube with water before and after feedings.
- B. Check gastric residual volume every 6 hours.
- C. Keep the head of the bed elevated at 30 degrees.
- D. Replace the NG tube every 24 hours.
Correct Answer: C
Rationale: Correct Answer: C - Keep the head of the bed elevated at 30 degrees.
Rationale:
1. Elevating the head of the bed at 30 degrees helps prevent aspiration by promoting proper drainage of gastric contents.
2. This position reduces the risk of reflux and pulmonary complications in clients with NG tubes.
3. It also helps maintain the proper position of the tube in the stomach, decreasing the likelihood of displacement.
Summary of Other Choices:
A. Flushing the NG tube with water before and after feedings is important for tube patency but does not directly prevent complications associated with the NG tube.
B. Checking gastric residual volume every 6 hours is important to monitor feeding tolerance but does not directly prevent complications related to the NG tube.
D. Replacing the NG tube every 24 hours is not necessary unless there are specific indications such as tube blockage or dislodgment. Regular replacement can increase the risk of complications and is not a standard practice.
During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.