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A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
- A. Store insulin at room temperature to prevent crystallization.
- B. Use insulin immediately after drawing it up into the syringe.
- C. Inject insulin into the same spot to avoid tissue damage.
- D. Rotate injection sites to prevent lipodystrophy.
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications.
A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration.
B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations.
C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
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A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should encourage the patient to:
- A. Avoid deep breathing exercises to prevent pain.
- B. Take shallow breaths to minimize pain.
- C. Perform deep breathing exercises to prevent pneumonia.
- D. Limit mobility to avoid stress on the surgical site.
Correct Answer: C
Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention.
Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia.
Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential.
Summary:
- A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications.
- B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia.
- D: Limiting mobility can lead to complications like blood clots and pneumonia.
Which of the following statements is an example of flight of ideas?
- A. My stomach hurts. Hurts, spurts, burts.
- B. Kiss, wood, reading, ducks, onto, maybe.
- C. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom.
- D. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.
A nurse is teaching a patient with diabetes about foot care. Which of the following statements by the patient indicates proper understanding?
- A. I will inspect my feet daily for cuts or blisters.
- B. I will wear tight shoes to avoid blisters.
- C. I will avoid trimming my toenails to prevent injury.
- D. I will not worry about foot care unless I experience pain.
Correct Answer: A
Rationale: The correct answer is A because daily inspection helps identify issues early, preventing complications. B is incorrect as tight shoes can cause blisters. C is wrong as proper toenail trimming is essential. D is incorrect because prevention is key in diabetic foot care.
Which of the following are considered second-level priority problems?
- A. Low self-esteem.
- B. Lack of knowledge.
- C. Abnormal laboratory values.
- D. Severely abnormal vital signs.
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.
Which of the following statements about nursing diagnoses is true? Nursing diagnoses:
- A. evaluate the etiology of disease.
- B. are a process based on medical diagnosis.
- C. evaluate the response of the whole person to actual or potential health problems.
- D. focus on the function and malfunction of a specific organ system in response to disease.
Correct Answer: C
Rationale: Rationale:
1. Nursing diagnoses evaluate the response of the whole person to health problems, not just specific organ systems.
2. They focus on the individual's physical, emotional, social, and spiritual well-being.
3. Nursing diagnoses are independent of medical diagnoses and consider the person holistically.
4. Option C aligns with the nursing process and the holistic approach of nursing care.
Summary:
Option A is incorrect as nursing diagnoses do not solely evaluate the etiology of disease. Option B is incorrect as nursing diagnoses are independent of medical diagnoses. Option D is incorrect as nursing diagnoses focus on the whole person, not just specific organ systems.