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The nurse is caring for a client with diabetes and develops a nursing diagnosis of ineffective health management related to insufficient knowledge of therapeutic regimen (resulting in low motivation). Which of the following client actions is the basis for this nursing diagnosis?
- A. Does not perform capillary blood glucose tests as directed
- B. Occasionally forgets to take the daily prescribed medication.
- C. Says that dietary intake does not seem to impact fatigue level.
- D. Cannot identify signs or symptoms of high and low blood glucose.
Correct Answer: C
Rationale: The client's motivation to follow a diabetic diet will be decreased if the client feels that dietary changes do not impact symptoms. The other responses do not indicate that the ineffective health maintenance is caused by lack of motivation.
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A client with newly diagnosed breast cancer has a nursing diagnosis of deficient knowledge related to insufficient information (about breast cancer). When the nurse is planning teaching for the client, which is the most important initial learning goal?
- A. The client will select the most appropriate breast cancer therapy.
- B. The client will state ways of preventing the recurrence of the tumour.
- C. The client will demonstrate coping skills needed to manage the disease.
- D. The client will choose methods to minimize adverse effects of treatment.
Correct Answer: A
Rationale: Adults learn best when given information that can be used immediately. The first action the client will need to take after a cancer diagnosis is to choose a treatment option. The other goals may be appropriate as treatment progresses.
A client admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing client teaching, which is the best action for the nurse to take?
- A. Instruct about the increased risk for cardiovascular disease.
- B. Provide detailed information about dietary control of glucose.
- C. Teach glucose self-monitoring and medication administration.
- D. Give information about the effects of exercise on glucose control.
Correct Answer: C
Rationale: When time is limited, the nurse should focus on the priorities of teaching. In this situation, the client should know how to test blood glucose and administer medications to control glucose levels. The client will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals.
The client's teaching plan includes this goal: 'The client will select foods lower in sodium from the hospital menu for the next 3 days.' Which evaluation method will be best for the nurse to use when determining whether teaching was effective?
- A. Check the sodium content of the client's menu choices over the next 3 days.
- B. Ask the client to identify which foods on the hospital menus are high in sodium.
- C. Have the client list favourite foods that are high in sodium and foods that could be substituted for these favourites.
- D. Compare the client's sodium intake over the next 3 days with the sodium intake before the teaching was implemented.
Correct Answer: A
Rationale: All of the answers address the client's sodium intake, but the desired client behaviours in the learning objective are most clearly addressed by evaluation of the client's menu choices.
The nurse is planning a teaching session for a client who needs to improve skills in being more assertive. Which of the following is the most effective teaching strategy for this client?
- A. Role playing
- B. Peer teaching
- C. Printed materials
- D. Lecture-discussion
Correct Answer: A
Rationale: Role playing allows the client to practise assertive behaviour and receive feedback about how the behaviour is perceived. This strategy is most often used when clients need to examine their attitudes and behaviours; understand the viewpoints and attitudes of others, or practise carrying out thoughts, ideas, or decisions. Lecture-discussion, peer teaching, and printed materials are more useful for other learning needs.
When assessing the learning needs for a client who has coronary heart disease, the nurse finds that the client has recently made dietary changes to decrease fat intake and has stopped smoking. Which of the following is the most appropriate initial statement by the nurse at this time?
- A. Although those are important, it is essential that you make other changes, too.
- B. Are you having any difficulty in maintaining the changes you have already made?
- C. You have already accomplished some changes that are important in heart health.
- D. Which additional changes in your lifestyle would you like to implement at this time?
Correct Answer: C
Rationale: Positive reinforcement of the learner's achievements is critical in making lifestyle changes. This client is in the action stage of the Transtheoretical Model, when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate, but are not the best initial response.