The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?
"I was monitoring my blood glucose every 3 to 4 hours."
"I had to stop my insulin."
"I called the doctor because of these symptoms."
None of the above.
The Correct Answer is B
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.
Therefore, these are not indications for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
Option A is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.
Option C is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.
Reasons why the other options are not correct answers:
Option A: Irrational fear of certain objects is more indicative of a phobia than OCD.
Option C: Clients with OCD are usually aware of their compulsions and may even try to resist them.
Correct Answer is C
Explanation
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
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