A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching?
“Wear closed-toed shoes daily.”
“Maintain stable blood glucose levels.”
“Plan to have an eye examination once per year.”
“Examine your feet carefully every day.”
The Correct Answer is B
Choice A reason: Wearing closed-toed shoes daily is a good practice for people with diabetes, as it can protect the feet from injuries and infections. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. These complications are mainly caused by high blood glucose levels that damage the blood vessels and nerves in the eyes and feet.
Choice B reason: Maintaining stable blood glucose levels is the most important action for preventing long-term complications of retinopathy and neuropathy. High blood glucose levels can cause oxidative stress, inflammation, and endothelial dysfunction, which impair the blood flow and oxygen delivery to the eyes and feet. This can lead to nerve damage (neuropathy) and vision loss (retinopathy) over time. Keeping blood glucose levels within the target range can reduce the risk of these complications and slow down their progression if they already exist.
Choice C reason: Planning to have an eye examination once per year is a recommended action for people with diabetes, as it can help detect and treat retinopathy before it causes irreversible damage to the retina. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. Eye examinations cannot prevent retinopathy from occurring or worsening; they can only monitor its status and provide appropriate interventions.
Choice D reason: Examining your feet carefully every day is another recommended action for people with diabetes, as it can help identify and treat any signs of neuropathy, such as numbness, tingling, pain, or ulcers. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. Foot examinations cannot prevent neuropathy from occurring or worsening; they can only monitor its status and provide appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Maintain the client in Fowler’s position. This is correct because Fowler’s position, which is a semi-sitting position with the head of the bed elevated 45 to 60 degrees, can facilitate the drainage of gastric contents and reduce the risk of aspiration.
Choice B: Use sterile water to irrigate the nasogastric tube. This is incorrect because sterile water is not necessary to irrigate the nasogastric tube, unless the client is immunocompromised or has a high risk of infection. Tap water or normal saline can be used to irrigate the nasogastric tube, following the provider’s orders or the facility’s protocol.
Choice C: Moisten the client’s lips with lemon-glycerin swabs. This is incorrect because lemon-glycerin swabs can dry out and irritate the client’s lips and oral mucosa, especially if used frequently. The nurse should use water-soluble lubricant or lip balm to moisturize the client’s lips and mouth.
Choice D: Measure abdominal girth daily. This is incorrect because measuring abdominal girth daily is not enough to monitor the progression of the intestinal obstruction and the effectiveness of the gastrointestinal decompression. The nurse should measure abdominal girth more frequently, such as every 4 hr or every shift, and report any changes or abnormalities.
Correct Answer is C
Explanation
Choice A reason: This test does not detect antithyroid antibodies in your blood. Antithyroid antibodies are proteins that atack the thyroid gland and can cause autoimmune thyroid diseases, such as Hashimoto’s thyroiditis or Graves’ disease. To detect antithyroid antibodies, you need a different blood test called the thyroid peroxidase (TPO) antibody test.
Choice B reason: This test does not measure the amount of thyroid hormone that ataches to a protein in your blood. Thyroid hormone can exist in two forms in the blood: free or bound. Free thyroid hormone is not atached to any protein and can enter the cells and tissues where it is needed. Bound thyroid hormone is atached to a protein called thyroxine-binding globulin (TBG) and cannot enter the cells and tissues. To measure the amount of thyroid hormone that ataches to TBG, you need a different blood test called the total thyroxine (T4) test.
Choice C reason: This test determines whether your thyroid gland is overactive, appropriately active, or underactive. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to make and release thyroid hormones, such as thyroxine (T4) and triiodothyronine (T3). These hormones regulate many body functions, such as metabolism, growth, and development. The TSH test measures the amount of TSH in the blood and reflects how well the thyroid gland is working. If the TSH level is high, it means that the thyroid gland is underactive (hypothyroidism) and not making enough thyroid hormones. If the TSH level is low, it means that the thyroid gland is overactive (hyperthyroidism) and making too much thyroid hormones.
Choice D reason: This test does not measure the absorption of iodine and how it relates to the thyroid gland. Iodine is a mineral that is essential for the production of thyroid hormones. The thyroid gland absorbs iodine from the food and water we consume and uses it to make T4 and T3. To measure the absorption of iodine by the thyroid gland, you need a different test called the radioactive iodine uptake (RAIU) test.
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