The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?

"Would you like to talk about what is bothering you?"

"Do you feel like practicing insulin injections now?"

"I know you are afraid, but I am here to help you."

"Before you can go home you must learn how to give insulin."

Answer and Explanation

The Correct Answer is A

A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.

B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.

C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.

D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.

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Correct Answer is C

Explanation

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

A. Cries vigorously when stimulated. B. Heart rate of 220 beats/minute. C. A positive Babinski reflex. D. Flexion of all four extremities.

Correct Answer is A

Explanation

A. Cries vigorously when stimulated. A vigorous cry is a positive sign that the infant's lungs are functioning well and that they are receiving adequate oxygenation, indicating a good transition to extrauterine life.

B. Heart rate of 220 beats/minute. A heart rate of 220 beats/minute is too high for a newborn and could indicate tachycardia or distress, not a normal transition.

C. A positive Babinski reflex. A positive Babinski reflex is a normal finding in newborns but is not directly related to their immediate transition to extrauterine life. It is a neurological reflex that indicates normal nervous system function.

D. Flexion of all four extremities. Flexion of all four extremities is a good sign of normal muscle tone and neurological function but does not directly indicate respiratory or circulatory adaptation to extrauterine life as clearly as a vigorous cry does.

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The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Correct Answer is C

Explanation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

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