A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet.

Encourage him to find activities to do with his friends that do not involve eating.

Advise him to take his own food with him when going to fast food restaurants with his friends.

Assist him in identifying popular fast foods that are within his meal plan for diabetes.

Answer and Explanation

The Correct Answer is D

A. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet: Restricting social activities can lead to feelings of isolation and negatively affect adherence. It does not teach the adolescent practical skills for managing diabetes in real-life situations.

B. Encourage him to find activities to do with his friends that do not involve eating: While alternative activities are beneficial, avoiding meals with friends is not realistic for a teen. The goal is to promote self-management skills, not complete avoidance of social situations.

C. Advise him to take his own food with him when going to fast food restaurants with his friends: Bringing food may help in some situations, but it does not encourage the adolescent to make informed choices or learn how to navigate typical social eating environments.

D. Assist him in identifying popular fast foods that are within his meal plan for diabetes: Teaching the teen how to select appropriate options from common fast food menus empowers him to adhere to his diet while maintaining social interactions. This approach promotes self-management, independence, and realistic coping strategies.

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Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

A. Notify the unit manager that an emergency court order is needed to allow surgery. B. Continue to provide life support until a thorough search for a guardian is completed. C. Carry on with surgical preparation of the client without a signed informed consent. D. Ask the client's friend to sign the informed consent since the client is unresponsive.

Correct Answer is C

Explanation

A. Notify the unit manager that an emergency court order is needed to allow surgery: Obtaining a court order can take significant time and is not feasible in a life-threatening emergency. Delaying surgery could result in serious harm or death.

B. Continue to provide life support until a thorough search for a guardian is completed: While life support stabilizes the client, delaying definitive treatment when immediate surgery is required may worsen outcomes. Emergency protocols allow treatment without consent in life-threatening situations.

C. Carry on with surgical preparation of the client without a signed informed consent: In emergencies where the client is unresponsive and immediate surgery is necessary to preserve life, healthcare providers can proceed without consent under the principle of implied consent. This ensures prompt, potentially life-saving intervention.

D. Ask the client's friend to sign the informed consent since the client is unresponsive: A friend does not have legal authority to provide consent unless formally designated as a healthcare proxy. Relying on the friend could delay urgent care and is not legally valid.

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A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Correct Answer is ["C","E","G"]

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

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