Nokea
The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?
- A. If he is vomiting, I shouldn't give him any insulin.
- B. I should bring him to the doctor if he develops a fever.
- C. If our grandchildren are sick, they probably shouldn't come to visit.
- D. I should call the doctor if he has nausea or abdominal pain lasting for more than 1 or 2 days.
Correct Answer: A
Rationale: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.
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The nurse is preparing a community educational presentation. The topic is the leading causes of death for people ages 12-19. The nurse knows that which of the following should be presented?
- A. unintentional injuries
- B. cancer
- C. homicide
- D. suicide
Correct Answer: A
Rationale: Unintentional injuries, primarily motor vehicle accidents, are the leading cause of death for ages 12-19. Cancer (B), homicide (C), and suicide (D) are significant but rank lower.
The client diagnosed with prostatitis asks the nurse, 'Why do I need to take a stool softener? The problem is with my urine, not my bowels!' Which response should the nurse make to the client?
- A. This is a standard medication prescription for anyone with a urine problem.
- B. This will keep the bowel free of feces, which helps decrease the swelling inside.
- C. Being constipated puts you at more risk for developing complications of prostatitis.
- D. This will help you prevent constipation because straining is painful with prostatitis.
Correct Answer: D
Rationale: Stool softeners prevent constipation, which can cause painful straining in clients with prostatitis, exacerbating discomfort. They are not standard for all urinary issues, do not directly reduce swelling, and constipation does not cause complications of prostatitis.
The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?
- A. Roast beef
- B. Fresh cantaloupe
- C. Broiled cheeseburger
- D. Mashed potato with gravy
Correct Answer: B
Rationale: To lower the risk of heart disease, the diet should be low in saturated fat with the appropriate number of total calories. The diet should include less red meat (roast beef, cheeseburger) and more white meat with the skin removed. Dairy products used should be low in fat, and foods with high amounts of empty calories (white gravy) should be avoided.
The nurse caring for a child with congestive heart failure who will be discharged to home provides instructions to the parents regarding the administration of digoxin. Which statement by the mother indicates a need for further teaching?
- A. I will mix the medication with food.
- B. I will check my child's pulse before giving the medication.
- C. If my child vomits after I give the medication, I will not repeat the dose.
- D. I will check the dose of medication with my husband before I give the medication.
Correct Answer: A
Rationale: Digoxin is a cardiac glycoside and should not be mixed with food or formula because this method may not ensure the child receives the entire dose if the food is not fully consumed. Checking the child's pulse, not repeating the dose after vomiting, and verifying the dose with another person are correct interventions to ensure safe administration.
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.