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The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?
- A. a schedule for blood glucose monitoring
- B. a list of low-carbohydrate snacks
- C. a contact list of healthcare providers
- D. a log for recording insulin administration
Correct Answer: A
Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.
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The healthcare provider provides teaching to a group of evacuees in a mass casualty center after a natural flooding disaster. Which information should the healthcare provider include in the teaching plan? (select one that does not apply.)
- A. wash all fruits and vegetables thoroughly in running tap water
- B. identify all sexual contacts since the evacuation process
- C. take all doses of prophylactic prescriptions for diarrhea
- D. clean hands using soap, clean water, or waterless antibacterial solutions
Correct Answer: B
Rationale: In the aftermath of a flooding disaster, educating evacuees on proper hygiene practices like washing fruits and vegetables, taking prophylactic prescriptions, and practicing hand hygiene is crucial to prevent the spread of diseases. Option B, identifying sexual contacts, is not relevant to preventing post-disaster health risks and should not be included in the teaching plan.
The healthcare provider is assessing a client who has a new arteriovenous fistula in the left arm for hemodialysis. Which finding requires immediate intervention?
- A. A thrill is palpable on the fistula.
- B. The client's arm is warm and red.
- C. The fistula has a bruit on auscultation.
- D. There is no bruit on auscultation.
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness in the client's arm suggest infection or thrombosis of the arteriovenous fistula, which requires immediate intervention to prevent complications. A thrill (A) is a normal finding in a functional arteriovenous fistula, indicating good blood flow. A bruit (C) is also a normal finding on auscultation of a functioning arteriovenous fistula, indicating proper blood flow. The absence of a bruit (D) may indicate a non-functioning fistula, which would need further evaluation but does not require immediate intervention as warmth and redness do.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?
- A. Hypertension.
- B. Diabetes mellitus.
- C. Inadequate lifestyle changes in diet and exercise.
- D. Increased risk of chronic illnesses.
Correct Answer: C
Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.
The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?
- A. Blood glucose level of 150 mg/dL.
- B. Weight gain of 2 pounds in 24 hours.
- C. Decreased urine output.
- D. Temperature of 100.3°F (37.9°C).
Correct Answer: C
Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.
The healthcare professional is developing a health education program for adolescents on the dangers of smoking. Which strategy is most likely to be effective?
- A. showing graphic images of the effects of smoking
- B. inviting former smokers to share their experiences
- C. providing statistical data on smoking-related illnesses
- D. distributing pamphlets on smoking cessation resources
Correct Answer: B
Rationale: Inviting former smokers to share their experiences is the most effective strategy because personal stories can have a powerful impact on adolescents and motivate them to avoid smoking. This approach makes the consequences of smoking more relatable and real, potentially influencing behavior change. Showing graphic images may be too harsh and could lead to desensitization or avoidance of the issue. Providing statistical data may not resonate as strongly with adolescents as personal stories. Distributing pamphlets, while informative, may not have the same emotional impact as hearing real-life experiences.