Nokea
The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first?
- A. Structure menus for adherence to diet.
- B. Teach with videotapes showing insulin administration to ensure competence.
- C. Encourage dependence on others to prepare the client for the chronicity of the disease.
- D. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment.
Correct Answer: D
Rationale: Assessing the client's ability to read syringe and glucose monitor markings is the first step, ensuring they can manage self-care. Structuring menus or teaching with videos assumes capability, and encouraging dependence is inappropriate.
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A nursing instructor asks a student to identify risk factors for and methods of preventing prostate cancer. Which statement by the student indicates the need for further teaching?
- A. Smoking increases the risk for this type of cancer.'
- B. A high-fat diet will assist in preventing this type of cancer.'
- C. A history of a sexually transmitted infection is a risk for this disease.'
- D. Men more than 50 years old should be monitored with a yearly digital rectal exam.'
Correct Answer: B
Rationale: Smoking, history of a sexually transmitted infection, and yearly digital examinations are accurate statements regarding the risks and prevention measures related to this type of cancer. Prostate cancer is a slow-growing malignancy of the prostate gland. A high intake of dietary fat is a risk factor for prostate cancer.
The nurse is monitoring fetal heart rate (FHR) on a laboring client. Which finding should be reported to the health care provider?
- A. FHR of 154 bpm with moderate variability
- B. FHR of 114 bpm with moderate variability
- C. FHR of 170 bpm lasting more than 10 minutes
- D. FHR of 156 bpm with minimal variability in a premature infant
Correct Answer: C
Rationale: FHR of 170 bpm for over 10 minutes indicates tachycardia, requiring immediate reporting. Other findings are within normal or less urgent ranges.
The clinic nurse is talking to a client who has just been prescribed hormone replacement therapy (HRT). Which statement about HRT by the nurse is correct?
- A. HRT decreases the risk of stroke.
- B. HRT increases the risk of osteoporosis.
- C. HRT decreases the risk of deep vein thrombosis.
- D. HRT increases the risk of coronary artery disease.
Correct Answer: D
Rationale: HRT increases the risk of coronary artery disease. It does not decrease stroke or DVT risk and helps prevent osteoporosis.
The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse should teach the client to report glucose levels that consistently exceed which level?
- A. 150 mg/dL (8.57 mmol/L)
- B. 200 mg/dL (11.42 mmol/L)
- C. 250 mg/dL (14.28 mmol/L)
- D. 350 mg/dL (20.0 mmol/L)
Correct Answer: C
Rationale: The normal blood glucose level ranges from 70 to 110 mg/dL (4 to 6 mmol/L), or as designated and preferred by the primary health care provider. The client with diabetes mellitus should be taught to report blood glucose levels that exceed 250 mg/dL (14.28 mmol/L), unless otherwise instructed by the primary health care provider. Options 1 and 2 are high levels but do not require primary health care provider notification. Option 4 is a high value; the client should report an elevated level before it reaches this point.
The nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply.
- A. Clear sclera
- B. Blurred vision
- C. Protruding cornea
- D. Increased tear production
- E. Diminished pupillary adaptation to darkness
- F. Increased ability to discriminate among colors
Correct Answer: B,E
Rationale: Age-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.