Nokea
The nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus. The nurse should recognize that which teaching plan component is most important initially?
- A. Knowledge of the diabetic diet
- B. Understanding of the diagnosis
- C. Monitoring of blood glucose levels
- D. Correct technique for administering insulin
Correct Answer: B
Rationale: Before educating about a disease process, it is important that the client understands the components of the disease process. After this teaching, the actual components of diet, blood glucose testing, and insulin injections can be taught.
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The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
- A. My son came to visit me yesterday.
- B. At least I can speak and answer questions.
- C. I have a problem turning my neck to the side.
- D. Look at me, I can no longer be the head of my family.
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
The nurse in the outpatient mental health clinic develops a plan of care for a client diagnosed with bulimia. The nurse determines that which goal is most important?
- A. The client will identify symptoms of electrolyte imbalance.
- B. The client will maintain dental appointments and oral hygiene.
- C. The client will attend appropriate community support groups.
- D. The client will abstain from binge-purge behaviors.
Correct Answer: D
Rationale: Abstaining from binge-purge behaviors is the primary goal for bulimia treatment, as these behaviors drive the disorder's physical and psychological harm. Other goals support recovery but are secondary to stopping the cycle.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
- A. participating in the mutual identification of patient outcomes.
- B. gathering accurate and sufficient patient-centered data.
- C. comparing patient responses and expected outcomes.
- D. carrying out interventions and coordinating care.
Correct Answer: D
Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery. Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified. Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase. Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
- A. Only refer to the client by gender
- B. Identify the client only by age
- C. Avoid using the client's name
- D. Discuss the client another time
Correct Answer: D
Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.