Nokea
Which client action indicates a need for further teaching about insulin administration?
- A. Using a new needle for each injection
- B. Storing insulin in the refrigerator
- C. Checking blood glucose before injecting
- D. Injecting insulin into a lipodystrophic area
Correct Answer: D
Rationale: Injecting insulin into a lipodystrophic area can impair absorption, indicating a need for further teaching on site rotation.
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Which nursing diagnosis should the nursing team consider when developing this client's care plan?
- A. Activity intolerance
- B. Self-care deficit
- C. Ineffective breathing
- D. Impaired swallowing
Correct Answer: B
Rationale: Acromegaly can cause joint pain and muscle weakness, contributing to self-care deficits.
Which interrelated concepts could be identified as actual or potential for a 56-year-old male client diagnosed with diabetes mellitus type 2? Select all that apply.
- A. Nutrition.
- B. Metabolism.
- C. Infection.
- D. Male reproduction.
- E. Skin integrity.
Correct Answer: A,B,C,E
Rationale: Nutrition, metabolism, infection, and skin integrity are impacted by type 2 diabetes due to dietary needs, glucose control, infection risk, and neuropathy. Male reproduction is less directly affected.
Which nursing interventions are most appropriate at this time? Select all that apply.
- A. Take the client's vital signs at least every hour.
- B. Press the client's vital signs at least every hour.
- C. Limit the client's activity.
- D. Administer antipyretics per order.
- E. Encourage a diet high in iodized salt.
- F. Make sure I.V. calcium gluconate is available.
Correct Answer: A,C,D,F
Rationale: In thyroid crisis, frequent vital sign monitoring, activity limitation, antipyretics, and availability of calcium gluconate address hypermetabolic state and potential hypocalcemia.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
Which sign/symptom indicates to the nurse the client is experiencing hypoparathyroidism?
- A. A negative Trousseau's sign.
- B. A positive Chvostek's sign.
- C. Nocturnal muscle cramps.
- D. Tented skin turgor.
Correct Answer: B
Rationale: A positive Chvostek’s sign (facial twitching) indicates hypocalcemia from hypoparathyroidism. Negative Trousseau’s, cramps, and turgor are less specific.