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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Client in room 303 is requesting snacks between meals.": While client preferences are important, this information is non-urgent and can be communicated through care plans or written notes. It does not directly impact immediate nursing care during a shift change.
B. "Client in room 304 has a laptop that they use for relaxation.": This is personal, non-clinical information and is not essential for safe and effective handoff communication. Shift reports should focus on medical status, treatment plans, or immediate needs.
C. "Client in room 302 has multiple visitors.": Visitor status is not a priority item in a shift report unless it directly affects client care, safety, or monitoring. Including such information can distract from more clinically significant updates.
D. "Client in room 301 is in the cardiac catheterization lab.": This is critical information because it reflects a current procedure, potential risks, and possible post-procedure care needs. Reporting this ensures continuity of monitoring and prioritization.
Correct Answer is D
Explanation
Rationale:
A. Tachypnea: An increased respiratory rate is not commonly associated with epidural anesthesia and is not a typical adverse effect. It may result from anxiety or pain but does not directly indicate a problem with the epidural.
B. Hyperreflexia: Epidurals often reduce sensation and reflexes, not heighten them. Hyperreflexia is not expected and would not be a direct adverse effect of epidural administration during labor.
C. Hypothermia: While mild temperature changes may occur, hypothermia is not a common or significant adverse effect of epidural anesthesia. It is not typically monitored as a key complication.
D. Hypotension: Epidural anesthesia can cause vasodilation by blocking sympathetic nerve fibers, leading to a drop in maternal blood pressure. This is a well-known and common adverse effect requiring close monitoring and potential intervention.
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