Nokea
The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?
- A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
- B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
- C. Review his glycosylated hemoglobin level 3 months after the teaching session.
- D. Have the adolescent list the steps for safe insulin administration.
Correct Answer: C
Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.
You may also like to solve these questions
A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?
- A. I am sorry, but your friend was killed in the accident.
- B. Right now you need to concentrate on getting well.
- C. Was the passenger in the car your friend?
- D. I think your friend is going to be all right.
Correct Answer: A
Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.
When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?
- A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
- B. Determine if the UAP also measured the client's capillary refill time.
- C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
- D. Notify the health care provider of the abnormal pulse rate and pulse volume.
Correct Answer: D
Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.
While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
- A. Apply a pressure dressing around the chest tube insertion site
- B. Assess the client for allergies to topical cleaning agents
- C. Measure the area of swelling and crackling
- D. Administer an oral antihistamine per PRN protocol
Correct Answer: A
Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.
A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, "Kill, Kill." What question should the nurse ask the client next?
- A. When did these voices begin?
- B. Are you planning to obey the voices?
- C. Have you taken any hallucinogens?
- D. Do you believe the voices are real?
Correct Answer: B
Rationale: Assessing whether the client has a plan to act on the voices is critical for evaluating the risk of harm. Asking if the client is planning to obey the voices helps determine the immediate safety concerns. While understanding when the voices began could provide insight into the situation, assessing the intent to act on them is more urgent. Asking about hallucinogen use may be relevant but does not address the immediate safety issue. Inquiring about the client's belief in the reality of the voices is important but does not address the immediate risk of harm.
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct Answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.