Nokea
A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
- A. prefers to take insulin orally.
- B. has type 1diabetes.
- C. has type 2 diabetes.
- D. is pregnant and has type 2 diabet
Correct Answer: C
Rationale: Oral antidiabetic agents are medications designed specifically for the management of type 2 diabetes mellitus. They work by improving insulin sensitivity, increasing insulin production, or reducing glucose production in the liver. Type 1 diabetes mellitus is characterized by an absolute deficiency of insulin production, requiring lifelong insulin therapy. Therefore, oral antidiabetic agents are not effective for individuals with type 1 diabetes like the client in this scenario.
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An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
- A. Assess for neurologic defects
- B. Place the child in the knee-chest position
- C. Begin cardiopulmonary resuscitation
- D. Prepare family for imminent death
Correct Answer: B
Rationale: When an 8-month-old infant has a hypercyanotic spell, the priority nursing action is to place the child in the knee-chest position. This position helps to increase venous return to the heart and improve systemic circulation, which can relieve the cyanosis by decreasing right-to-left shunting of blood. Placing the child in the knee-chest position helps optimize oxygenation and circulation, which is crucial during a hypercyanotic spell. Assessing for neurologic defects, beginning cardiopulmonary resuscitation, or preparing the family for imminent death are not the priority actions during a hypercyanotic spell in this scenario.
A nurse is working with a dying client and his family. Which communication technique is most important to use?
- A. Reflection
- B. Clarification
- C. Interpretation
- D. Active listening
Correct Answer: D
Rationale: Active listening is the most important communication technique to use when working with a dying client and their family. This technique involves the nurse fully concentrating, understanding, responding, and remembering what is being said. By actively listening, the nurse can provide empathy, support, and validation to the client and their family members during this emotionally challenging time. This technique helps in creating a safe and supportive environment for honest and open communication, allowing the nurse to assess and address the needs and concerns of both the client and their family effectively.
Angie is an adolescent who has seizure disorder; which of the following would not be a focus of a teaching program?
- A. Ability to obtain a driver's license
- B. Drug and alcohol abuse
- C. Increased risk of infections
- D. Peer pressure
Correct Answer: A
Rationale: The correct answer is A, ability to obtain a driver's license. This would not be a focus of a teaching program for Angie with a seizure disorder since individuals with uncontrolled seizures are typically not allowed to have a driver's license due to safety concerns. It is important for Angie to understand the risks and consequences of drug and alcohol abuse, the increased risk of infections, and how to handle peer pressure effectively in relation to her condition. These topics are more relevant to managing her health and well-being with a seizure disorder.
An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
- A. Diarrhea
- B. Amenorrhea
- C. Cold intolerance
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors such as vomiting. The frequent exposure of the teeth to stomach acid during vomiting can lead to erosion of tooth enamel. This can result in dental issues such as decay, sensitivity, and discoloration. Therefore, erosion of tooth enamel is a common assessment finding in individuals with bulimia. The other options (A. Diarrhea, B. Amenorrhea, C. Cold intolerance) are not typically associated with bulimia.
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted?
- A. Appropriate because of child's age
- B. Appropriate because mother would be uncomfortable making decisions for child
- C. Inappropriate because of child's age
- D. Inappropriate because child is same sex as mother
Correct Answer: A
Rationale: It is appropriate for the nurse to offer the 10-year-old girl the option of having her mother stay in the room during the physical assessment because of the child's age. At this age, children may start to seek more independence and privacy, and allowing the child to make the decision can help promote a sense of autonomy and respect for her feelings. It is important to consider the child's preferences and comfort during medical procedures, which can help build trust and improve the overall experience for the child.