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A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
- A. Maintenance of blood glucose levels between 180 and 200mg/dl
- B. Smoking reduction but not complete cessation
- C. An eye examination every 2 years until age 50
- D. Exercise and a weight reduction diet
Correct Answer: D
Rationale: For a client with newly diagnosed type 2 diabetes mellitus, the primary focus should be on lifestyle modifications to help manage the condition. A key component of managing type 2 diabetes is maintaining a healthy weight through a balanced diet and regular exercise. Regular physical activity can help improve insulin sensitivity and can assist in weight management. A weight reduction diet can help control blood sugar levels and reduce the risk of complications associated with diabetes. Therefore, incorporating education on exercise and a weight reduction diet is essential in optimizing the client's health outcomes and quality of life.
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Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: In caring for a patient with expressive aphasia like Mr. Reyea, providing positive feedback when he uses a word correctly is essential for reinforcing and encouraging communication efforts. This positive reinforcement can help boost his confidence and motivation to continue trying to communicate effectively. It is important to support and acknowledge any progress made, as communication difficulties can be frustrating for individuals with aphasia. Waiting for him to verbally state needs regardless of how long it may take, as well as suggesting that he get help at home because the disability is permanent, may not be the most therapeutic or supportive approaches. Helping the family accept that Mr. Reyea cannot participate in verbal communication should not be the primary focus, as there are strategies and therapies that can help improve communication abilities in patients with aphasia.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
gauge needle for drawing up medication and injecting it
- A. Inject the medication in the upper arm muscle
- B. Use a 1 inch needle to administer the medication
- C. Use the Z track technique to administer the medication
Correct Answer: B
Rationale: Using a 1 inch needle is the appropriate gauge needle for drawing up medication and injecting it. The length of the needle is important to ensure that the medication reaches the intended target area and is administered effectively. Shorter needles may not penetrate deep enough, while longer needles may increase the risk of complications such as injecting the medication into the wrong tissue or causing discomfort to the patient. Therefore, using a 1 inch needle is the correct choice for administering medication safely and accurately.
A 4-month old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest . The nurse is aware this finding can be attributed to:
- A. Anemia
- B. Hypovolemia
- C. Pulmonary edema
- D. Metabolic acidosis blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
Correct Answer: C
Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: Lymphocytes are a type of white blood cell that plays a crucial role in the body's immune system by helping to fight off infections and diseases. A decrease in the number of lymphocytes with age means that the immune system may not function as effectively as it used to. This can lead to a decreased resistance to infections, making older individuals more susceptible to illnesses and diseases. Therefore, the effect of a decrease in the number of lymphocytes with age is a decreased resistance to infection.