The nurse is assessing an older adult with type 2 diabetes mellitus. Whichassessment
... [Show More] findingindicatesthattheclientunderstandslong-termcontrolofdiabetes?
• The fatingblood sugarwas120mg/dlthismorning.
• Urineketoneshavebeennegative forthepast6months
• The hemoglobinA1Cwas6.5g/100mllastweek
• Nodiabeticketoacidosishasoccurredin6months.
• Rationale: A hemoglobin A1C level reflects he average blood sugar the client hadover the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the clientunderstand long-term diabetes control. Normal value in a diabetic patient is up to6.5g/100 ml.
A client with rheumatoid arthritis (RA) starts a new prescription of etanercept(Enbrel)subcutaneouslyonceweekly.Thenurseshouldemphasizetheimportanceofreportingproblem tothehealthcareprovider?
• Headache
• Jointstiffness
• Persistentfever
• Increasehungerandthirst
• Rationale:Enbreldecreaseimmuneand inflammatoryresponses,increasingtheclient’s risk of serious infection, so the client should be instructed to report apersistentfever,orothersignsofinfectiontothehealthcareprovider.
• An older male client is admitted with the medical diagnosis of possible cerebralvascular accident (CVA). He has facial paralysis and cannot move his left side. Whenentering the room, the nurse finds the client’s wife tearful and trying unsuccessfully togivehimadrinkofwater. Whataction shouldthenursetake?
• Askthewifetostopandassesstheclient’sswallowingreflex
• A 13 years-old client with non-union of a comminuted fracture of the tibia isadmittedwithosteomyelitis.Thehealthcareprovidercollects homeaspiratespecimensfor culture and sensitivity and applies a cast to the adolescent’s lower leg. What actionshouldthenurseimplementnext?
• Administerantiemeticagents
• Bivalvethecast fordistalcompromise
• Providehigh-calorie, high-proteindiet
• Beginparenteralantibiotictherapy
• Rationale: The standard of treatment for osteomyelitis is antibiotic therapy andimmobilization.Afterbondandbloodaspiratespecimensareobtainedforcultureandsensitivity,the nurseshouldinitiateparenteralantibioticsasprescribed.
• The nurse is preparing a community education program on osteoporosis. Whichinstructionishelpfulinpreventingbonelossandpromotingboneformation?
• Recommendweighbearingphysicalactivity
• A client with a history of chronic pain requests a nonopioid analgesic. The clientisalertbut hasdifficultydescribingtheexact nature andlocationofthepaintothenurse.Whatactionshouldthenurseimplementnext?
• Administertheanalgesicasrequested
• A male client receives a thrombolytic medication following a myocardialinfarction. When the client has a bowel movement, what action should the nurseimplement?
• Send stoolsampletothelab foraguaiactest
• Observestoolforaday-coloredappearance.
• Obtainspecimenforcultureandsensitivityanalysis
• Assesfor fattyyellowstreaksintheclient’sstool.
• Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac(occultbloodtest)testofthestoolshouldbeevaluatedtodetectbleedingintheintestinaltract.
• The mother of a child with cerebral palsy (CP) ask the nurse if her child’simpairedmovementswillworsenasthechildgrows.Whichresponseprovidesthebestexplanation?
• BraindamagewithCPisnotprogressivebutdoes haveavariablecourse
• During shift report, the central electrocardiogram (EKG) monitoring systemalarms.Whichclientalarmshould thenurseinvestigatefirst?
• Respiratoryapneaof30seconds
• Inearlysepticshockstates,whatis theprimarycauseof hypotension?
• Peripheralvasoconstriction
• Peripheralvasodilation
• Cardiacfailure
• Avagalresponse [Show Less]