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A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?
- A. I should avoid taking bubble baths.
- B. I will need to empty my bladder after having sexual intercourse.
- C. I will need to wipe my perineal area from back to front after urination.
- D. I need to drink at least 8 full glasses of liquid each day.
Correct Answer: C
Rationale: Wiping from back to front can transfer bacteria to the urethra, increasing UTI risk, indicating a need for further teaching on proper hygiene.
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A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Frothy sputum.
- B. Dependent edema.
- C. Jugular distention.
- D. Nocturnal polyuria.
Correct Answer: A
Rationale: Frothy sputum is a symptom of left-sided heart failure due to pulmonary congestion and edema.
A nurse is collecting data from a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider?
- A. Client reports feeling depressed.
- B. Joint pain in hands and knees.
- C. Dry, raised rash on the face.
- D. Presence of peripheral edema.
Correct Answer: D
Rationale: Peripheral edema is the highest priority as it may indicate kidney involvement, a serious SLE complication requiring immediate attention.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply)
- A. Polyuria.
- B. Sweating.
- C. Blurry vision.
- D. Tachycardia.
- E. Polydipsia.
Correct Answer: B,C,D
Rationale: Sweating, blurry vision, and tachycardia are manifestations of hypoglycemia due to adrenaline release and glucose deficiency affecting bodily functions.
A nurse is collecting data from a client who has diabetes mellitus. The client is confused, flushed, and has an acetone odor on his breath. The nurse should anticipate a prescription for which of the following types of insulin to treat the client?
- A. Regular.
- B. NPH.
- C. Glargine.
- D. Detemir.
Correct Answer: A
Rationale: Regular insulin is a short-acting insulin used to treat diabetic ketoacidosis (DKA), which is indicated by the client's symptoms of confusion, flushed appearance, and acetone odor on the breath.
An adult client newly diagnosed with type 2 diabetes mellitus asks a nurse to explain how he developed the condition. Which of the following responses should the nurse make?
- A. Your body will continue producing too much insulin without medicine to counteract it.
- B. Your body doesn't process glucose well.
- C. Your body's hemoglobin is not binding to the sugar you consume.
- D. Your body's immune system has destroyed cells in your pancreas.
Correct Answer: B
Rationale: Type 2 diabetes involves insulin resistance, where the body cannot process glucose effectively, leading to elevated blood glucose levels.