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The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse discuss as an example of a primary nursing intervention?
- A. Monitor for elevated blood glucose at random intervals.
- B. Inspect the skin and sclera of the eyes for a yellow tint.
- C. Limit meat in the diet and eat a diet low in fat.
- D. Instruct the client with hyperglycemia about insulin injections.
Correct Answer: C
Rationale: A low-fat diet reduces pancreatic stress, a primary prevention strategy. Glucose monitoring, jaundice inspection, and insulin teaching are secondary or tertiary.
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Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism?
- A. I just don't seem to have any appetite anymore.
- B. I have a bowel movement about every three (3) to four (4) days.
- C. My skin is really becoming dry and coarse.
- D. I have noticed all my collars are getting tighter.
Correct Answer: D
Rationale: Tight collars suggest goiter, a hyperthyroidism symptom. Anorexia, constipation, and dry skin are hypothyroid-related.
The nurse knows the diabetic client understands what 'free' foods on the exchange list means if the client excludes which one of the following from a meal plan?
- A. Iced tea
- B. Flavored water
- C. Light beer
- D. Club soda
Correct Answer: C
Rationale: Light beer contains carbohydrates and calories, unlike free foods such as iced tea, flavored water, and club soda.
The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
Correct Answer: 3 units
Rationale: Per the sliding scale, a glucose of 189 (151–200 range) requires 3 units of Humalog.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client?
- A. Instruct the client to decrease alcohol intake.
- B. Explain the need to avoid all stress.
- C. Discuss the importance of stopping smoking.
- D. Teach the correct way to take pancreatic enzymes.
Correct Answer: A
Rationale: Decreasing alcohol intake is critical, as alcohol is a major cause of pancreatitis. Stress avoidance is unrealistic, smoking is secondary, and enzymes are for chronic cases.
A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available?
- A. Tracheostomy set
- B. Thoracotomy tray
- C. Dressing set
- D. Ice collar
Correct Answer: A
Rationale: A tracheostomy set is essential post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.