Nokea
The nurse is teaching a client the proper technique for using a cane. Which statements should the nurse include in the teaching? Select all that apply.
- A. Hold the cane on the affected side.
- B. Hold the cane on the unaffected side.
- C. Move the cane at the same time as the affected leg.
- D. Move the cane at the same time as the unaffected leg.
- E. Hold the cane 8 to 10 inches from the side of the foot.
Correct Answer: B,C
Rationale: The cane is held on the unaffected side and moved with the affected leg to provide support. The cane is held closer to the body, not 8-10 inches away.
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Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?
- A. Type 1 diabetes occurs due to increased carbohydrate intake and lack of exercise
- B. Type 1 diabetes is managed through diet and exercise
- C. Type 1 diabetes is caused by destruction of beta cells in the pancreas
- D. Type 1 diabetes leads to the body's cells rejecting insulin
Correct Answer: C
Rationale: Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy. Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits. Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.
Which of the following conditions may warrant a serum creatinine level?
- A. Rhabdomyolysis
- B. Digitalis toxicity
- C. Glomerulonephritis
- D. All answers are correct
Correct Answer: D
Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
A client diagnosed with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. On the basis of this analysis, the nurse should tell the client that it is best to avoid which food to minimize the risk of recurrence?
- A. Pasta
- B. Lentils
- C. Lettuce
- D. Spinach
Correct Answer: D
Rationale: Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion and predispose to stone formation include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, almonds, cashews, rhubarb, and tea. Pasta, lentils, and lettuce are not high in oxalates and are generally safe for clients with calcium oxalate stones.
A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication?
- A. This medication can cause severe drowsiness.
- B. The client must avoid foods that contain tyramine.
- C. The medication is associated with a high rate of abuse.
- D. The medication will begin to alleviate symptoms of depression almost immediately.
Correct Answer: B
Rationale: MAOIs are used to treat depression. Although MAOIs usually produce hypotension as a side effect, potentially lethal hypertension can occur if the client eats foods that contain tyramine. Such foods include aged cheeses, hot dogs, and beer, among others. The medication does not cause drowsiness, is not associated with a high rate of abuse, and does not act almost immediately.
The clinic nurse instructs a client diagnosed with diabetes mellitus about preventing diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching?
- A. I need to stop my insulin if I am vomiting.
- B. I need to call my doctor if I am ill for more than 24 hours.
- C. I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours.
- D. I need to drink small quantities of fluid every 15 to 30 minutes.
Correct Answer: A
Rationale: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The client needs to be instructed to continue taking insulin, even if vomiting and unable to eat, to prevent ketoacidosis. It is important to self-monitor blood glucose more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is more than 250 mg/dL, the client should test for urine ketones and contact the primary health care provider. Calling the doctor if ill for more than 24 hours, consuming 10 to 15 g of carbohydrates every 1 to 2 hours, and drinking small quantities of fluid every 15 to 30 minutes are accurate interventions to maintain hydration and glucose control during illness.