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The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1
diabetes. Which question is most appropriate for the nurse to ask?
- A. "Are you anorexic?"
- B. "Is your urine dark colored?"
- C. "Have you lost weight lately?"
- D. "Do you crave sugary drinks?"
Correct Answer: C
Rationale: The correct answer is C. This question is most appropriate as unintentional weight loss is a common symptom of type 1 diabetes due to the body's inability to properly use glucose for energy. The nurse should ask about weight loss to assess the patient's overall health status.
Explanation:
A: Asking about anorexia assumes a specific eating disorder, which may not be relevant to the patient's symptoms of diabetes.
B: Dark colored urine may indicate dehydration, but it is not specific to type 1 diabetes symptoms.
D: Craving sugary drinks may suggest a preference for sweet beverages but does not directly relate to the onset of type 1 diabetes symptoms.
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Which of the following statements is true regarding nursing ethics?
- A. Nursing ethics focus on the organizational level at the workplace.
- B. Nursing ethics focus on the duties and rules of behavior for professional nurses.
- C. Nursing ethics focus on the moral character of nurses.
- D. Nursing ethics focus on the experiences and needs of nurses.
Correct Answer: D
Rationale: Step 1: Nursing ethics encompass principles guiding ethical decision-making.
Step 2: Focusing on the experiences and needs of nurses ensures ethical care delivery.
Step 3: Understanding nurse perspectives enhances patient-centered care.
Step 4: Organizational level (A) is limited, duties and rules (B) are important but not the sole focus, and moral character (C) is crucial but not the main emphasis.
The staff nurse delegates AM care for two patients to the UAP (Unlicensed Assistive Person). What principle of delegation is the nurse following?
- A. Delegation requires a situation with clearly defined superiors.
- B. Delegation can only exist with a subordinate.
- C. Delegation is a tool used by various healthcare professionals.
- D. You can delegate only those tasks.
Correct Answer: D
Rationale: The correct answer is D because delegation involves transferring responsibility for a task while retaining accountability for the outcome. The nurse has delegated specific tasks (AM care) to the UAP, which aligns with the principle that only certain tasks can be delegated. Choice A is incorrect because delegation does not require clearly defined superiors, but rather defined tasks. Choice B is incorrect as delegation can also occur between peers or team members. Choice C is incorrect as delegation is not exclusive to healthcare professionals but is a common practice in various industries.
What information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?
- A. Select flat-soled leather shoes
- B. Apply heating pads on a low temperature.
- C. Avoid using callus remover for corns or calluses.
- D. Refrain from soaking feet in warm water for an hour each day.
Correct Answer: A
Rationale: The correct answer is A: Select flat-soled leather shoes. This choice is important for a patient with peripheral arterial disease, type 2 diabetes, and sensory neuropathy as it helps prevent skin breakdown, reduce pressure on the feet, and minimize the risk of injury due to decreased sensation. Flat-soled leather shoes provide good support and protection.
Explanation for why the other choices are incorrect:
B: Apply heating pads on a low temperature - This can be dangerous for a patient with sensory neuropathy as they may not be able to feel if the heating pad is too hot, leading to burns.
C: Avoid using callus remover for corns or calluses - While it is important to avoid injuring the skin, addressing foot care is not as critical as selecting appropriate footwear.
D: Refrain from soaking feet in warm water for an hour each day - Prolonged soaking can increase the risk of skin breakdown and infections, so it is important to avoid this practice.
Which level in Maslow's hierarchy is rarely met?
- A. Esteem
- B. Safety
- C. Self-actualization
- D. Belongingness
Correct Answer: C
Rationale: The correct answer is C: Self-actualization. This level in Maslow's hierarchy is rarely met because it represents the highest level of personal growth and fulfillment, where individuals achieve their full potential and self-realization. Most people do not reach this level as it requires a deep understanding of oneself and a continuous journey of personal development. Esteem (A), Safety (B), and Belongingness (D) are more basic needs that are relatively easier to fulfill compared to self-actualization. These lower levels focus on physical and social needs that are essential for survival and well-being, whereas self-actualization involves achieving one's highest aspirations and inner fulfillment.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct Answer: A
Rationale: The correct answer is A. The elevated blood pressure of 144/82 mm Hg indicates dehydration due to vomiting and diarrhea, leading to hypovolemia. This is a compensatory mechanism by the body to maintain perfusion. Option B, urine specific gravity of 1.03, indicates concentrated urine and dehydration, but not as specific as elevated blood pressure. Option C, neck vein distention, is more indicative of heart failure or fluid overload rather than dehydration. Option D, urine specific gravity of 1.01, indicates diluted urine and is not consistent with dehydration. Therefore, based on the symptoms and the compensatory mechanism of the body, an elevated blood pressure is the most likely finding in a client with vomiting and diarrhea.