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An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give?
- A. You can go out with them, but you should take your own snack with you.'
- B. Yes. You will learn what foods are allowed so you can eat with your friends.'
- C. When you get food out in a restaurant, be sure to order diet soft drinks.'
- D. Eating out will not be possible on a diabetic diet. Why don't you plan to invite your friends to your house?'
Correct Answer: B
Rationale: Learning appropriate food choices allows the adolescent to eat out safely, promoting social integration and adherence to the diabetic diet.
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Which client action indicates a need for further teaching about insulin administration?
- A. Using a new needle for each injection
- B. Storing insulin in the refrigerator
- C. Checking blood glucose before injecting
- D. Injecting insulin into a lipodystrophic area
Correct Answer: D
Rationale: Injecting insulin into a lipodystrophic area can impair absorption, indicating a need for further teaching on site rotation.
Which nursing interventions are most appropriate at this time? Select all that apply.
- A. Take the client's vital signs at least every hour.
- B. Press the client's vital signs at least every hour.
- C. Limit the client's activity.
- D. Administer antipyretics per order.
- E. Encourage a diet high in iodized salt.
- F. Make sure I.V. calcium gluconate is available.
Correct Answer: A,C,D,F
Rationale: In thyroid crisis, frequent vital sign monitoring, activity limitation, antipyretics, and availability of calcium gluconate address hypermetabolic state and potential hypocalcemia.
Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis?
- A. Temperature.
- B. Pulse.
- C. Respirations.
- D. Blood pressure.
Correct Answer: D
Rationale: Elevated blood pressure is a hallmark of aldosteronism due to sodium retention and fluid overload. Temperature, pulse, and respirations are less specific.