Nursing assessment of a client with type 2 diabetes reveals that the client is 5' 6" tall (167.6 cm), weighs 238 pounds (108.2 Kg), works behind a desk all day, does not exercise, and smokes 2 packs of cigarettes daily. In planning care for this client, which intervention is most important for the nurse to implement?

Instruct the client to decrease number of cigarettes smoked daily.

Discuss changing eating habits with a goal of losing 2 pounds (1 kg) per week.

Encourage other family members to be tested for diabetes mellitus.

Determine the client's feelings about being diagnosed with a chronic disease.

Answer and Explanation

The Correct Answer is B

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

A. Inform the client that oatmeal contains gluten. B. Encourage the client to choose decaffeinated coffee. C. Commend the client for selecting fat free milk. D. Advise the client that too much fruit can irritate the colon.

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving morning report about four clients, which client should the nurse attend to first?

Correct Answer is D

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

A client reports feeling numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) review before reporting the finding?

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

A client who is multiparous on the postpartum unit reports intense cramping while breastfeeding. What instruction should the nurse provide to this client?

A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which intervention reflects a primary prevention strategy the nurse might initiate to combat this chronic illness?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse Implement?