A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for a dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care?
"I can assist you with making a list of foods you like for the dietitian."
"I understand that the dietary choices can seem overwhelming."
"Managing your diabetes will require you to make accommodations."
"The dietitian will provide you with the best food choices to manage your diabetes."
The Correct Answer is A
Choice A reason: This statement encourages the client's involvement by offering assistance in creating a personalized list of preferred foods, which can then be discussed with the dietitian. It promotes a collaborative approach to the dietary plan, allowing the client to have a say in their food choices, which is essential for long-term adherence and management of type 2 diabetes.
Choice B reason: While this statement shows empathy, it does not actively encourage the client's involvement in their care. Understanding the challenges is important, but it is more beneficial to empower the client to take an active role in managing their dietary choices.
Choice C reason: This statement is factual, as managing diabetes does require accommodations. However, it does not directly encourage the client's involvement. Instead, it could be more encouraging by suggesting ways the client can participate in making those accommodations.
Choice D reason: Informing the client that the dietitian will provide the best food choices is reassuring but does not facilitate the client's involvement. It positions the dietitian as the sole decision-maker rather than including the client as an active participant in their dietary planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Mantoux skin test, also known as the tuberculin skin test, measures the immune response to the tuberculin purified protein derivative injected into the skin. An induration of less than 1 mm is not considered a positive result. However, the size of the induration in the Mantoux test does not indicate whether the person is infectious or not.
Choice B reason: Negative sputum cultures for acid-fast bacillus (AFB) are a strong indication that the client is no longer infectious. Pulmonary tuberculosis is diagnosed and monitored by the presence of AFB in the sputum. When the sputum cultures are negative, it suggests that the client is not excreting the bacteria and is less likely to spread the infection to others.
Choice C reason: While no longer coughing up blood-tinged sputum is a sign of clinical improvement, it does not necessarily mean that the client is no longer infectious. The absence of blood in the sputum may indicate reduced inflammation or healing of lung tissue, but the client could still be capable of transmitting tuberculosis if AFB is present in the sputum.
Choice D reason: The Quantiferon-TB Gold test is a blood test that measures the immune response to Mycobacterium tuberculosis antigens. A positive result indicates that the person's immune system has been exposed to the bacteria, but it does not determine if the person is infectious. The term "positive (negative)" is contradictory and does not provide clear information about the client's infectious status.
Correct Answer is C
Explanation
Choice A reason: Dry areas around the pins can be a normal finding if the pin sites are healing properly. It indicates that there is no excessive moisture that could promote bacterial growth and infection. However, the nurse should continue to monitor for any signs of redness, swelling, or pain that could indicate a developing infection.
Choice B reason: Crusts around the pins are typically a sign of dried exudate, which can be part of the normal healing process. The crusts should be monitored and cleaned according to the healthcare facility's protocol to prevent infection. If the crusts are accompanied by other signs of infection, such as redness, warmth, or purulent drainage, they should be reported to the healthcare provider.
Choice C reason: Purulent drainage around the pins is a sign of infection and should be reported immediately to the unit care coordinator. Infections at pin sites can lead to complications such as osteomyelitis, delayed healing, or even systemic infection. Prompt intervention with appropriate cleaning and possibly antibiotics is necessary to prevent further complications.
Choice D reason: The absence of pain at the site can be a normal finding and is not typically a cause for concern unless there is an expectation of pain based on the patient's condition or recent procedures. However, a complete lack of sensation could indicate nerve damage or other issues, so the nurse should assess for other signs of neurovascular compromise and report any concerns to the healthcare provider.
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