A nurse is teaching a client who was recently diagnosed with type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

"I will drink half of a cup of fruit juice when I feel shaky and weak."

"I will soak my feet in water before applying lotion between my toes."

"I will skip a snack if I'm not hungry after lunch."

"I will only go without socks and shoes when I am in my home."

Answer and Explanation

The Correct Answer is A

Rationale:

A. "I will drink half of a cup of fruit juice when I feel shaky and weak.": Shakiness and weakness are early signs of low blood glucose, and consuming 15 grams of a fast-acting carbohydrate like ½ cup of fruit juice is an appropriate immediate response.

B. "I will soak my feet in water before applying lotion between my toes.": Diabetic clients should avoid soaking their feet due to the risk of skin maceration and infection. Lotion should not be applied between the toes, as this can promote fungal growth in a moist environment.

C. "I will skip a snack if I'm not hungry after lunch.": Skipping snacks can lead to hypoglycemia, especially if insulin has been administered. Even when not hungry, small carbohydrate intake may be necessary depending on the insulin regimen and activity level.

D. "I will only go without socks and shoes when I am in my home.": Diabetic clients should always wear protective footwear, even at home, to avoid undetected foot injuries that can lead to ulcers or infections due to impaired sensation and circulation.

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Correct Answer is C

Explanation

Rationale:

A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.

B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.

C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.

D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.

A. Make an audio recording of the adolescent's responses B. Promise not to disclose information shared during the interview C. Obtain a history from both the adolescent and their caregiver. D. Use leading questions during the interview.

Correct Answer is C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

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A nurse is teaching a client who was recently diagnosed with type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

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