Nokea
The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
- A. Use commercial preparations to remove
- B. Wash and inspect the feet daily
- C. Walk barefoot at least once each daily
- D. Cut the toenails by rounding edges
Correct Answer: B
Rationale: Clients with diabetes mellitus are at a higher risk for developing foot problems due to nerve damage and poor circulation. Washing and inspecting the feet daily is crucial in preventing and identifying any foot issues early. This practice helps in maintaining good foot hygiene, detecting any cuts, sores, or infections promptly, and preventing complications like diabetic foot ulcers. Walking barefoot is not recommended as it increases the risk of injury and infection, and cutting toenails by rounding edges can lead to ingrown toenails. Commercial preparations for foot care may contain ingredients that can be harmful to people with diabetes, so it is important to consult healthcare providers before using them.
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the most dangerous complication of untreated hypothyroidism is
- A. mental retardation.
- B. hypertension.
- C. low weight gain.
- D. sensitivity to heat.
Correct Answer: A
Rationale: The most dangerous complication of untreated hypothyroidism is mental retardation, especially in infants and children. Thyroid hormones play a vital role in the brain development of infants and young children. Severe and prolonged hypothyroidism during this critical period can lead to irreversible cognitive impairment, affecting intelligence and neurodevelopment. Therefore, timely diagnosis and treatment of hypothyroidism are essential to prevent this serious complication, particularly in children.
Where in the health history should the nurse describe all details related to the chief complaint?
- A. Past history
- B. Chief complaint
- C. Present illness
- D. Review of systems
Correct Answer: C
Rationale: The nurse should describe all details related to the chief complaint under the "Present illness" section of the health history. This section focuses specifically on the patient's current health problem, including the onset, duration, severity, aggravating or alleviating factors, and associated symptoms. It provides a comprehensive understanding of the chief complaint and helps guide further assessment and treatment interventions. The "Chief complaint" section typically contains a concise statement from the patient regarding the main reason for seeking healthcare.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.
A 5-year old girl presents to ER with fever, convulsions and unconsciousness of one day duration. On examination she is pale, Glasgow coma scale is 8 and there are no signs of meningial irritation and no focal neurological signs. The most likely diagnosis is:
- A. Viral encephalitis
- B. Pyomeningitis
- C. Tuberculous meningitis
- D. Cerebral malaria
Correct Answer: D
Rationale: Cerebral malaria can cause fever, seizures, altered consciousness, and normal cerebrospinal fluid findings without focal neurological signs.
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.