A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
Obtain capillary blood glucose level every 2 hr
Check the neurovascular status of the client's lower extremities every hour
Apply a cold pack to the client's ankle for 30 min every hour
Maintain the affected ankle elevated and immobilized
The Correct Answer is C
- A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
- B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
- C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
- D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
Correct Answer is B
Explanation
Use a reward system to modify the child's behavior.
Rationale:
- A. Incorrect. Maintaining a flexible daily schedule for the child may increase their anxiety and confusion, as they may have difficulty adapting to changes in routine and expectations. The nurse should advise the parents to establish a consistent and structured schedule for the child, with clear rules and boundaries.
- B. Correct. Using a reward system to modify the child's behavior is an effective strategy to reinforce positive behaviors and reduce negative ones. The nurse should help the parents identify specific and measurable goals for the child, and provide them with praise, tokens, or privileges when they achieve them.
- C. Incorrect. Providing a variety of family members to care for the child may overwhelm them and impair their social skills development, as they may have difficulty forming attachments and communicating with different people. The nurse should encourage the parents to select one or two primary caregivers for the child, who can provide them with consistent and supportive interactions.
- D. Incorrect. Administering alprazolam as needed to reduce the child's anxiety is not recommended, as it may cause adverse effects such as sedation, dependence, or withdrawal symptoms. The nurse should educate the parents about nonpharmacological interventions for anxiety, such as relaxation techniques, cognitive behavioral therapy, or social skills training.
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