When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room.
Which action should the nurse take?

Refer client to the social worker for support therapy.

Encourage client to implement relaxation techniques.

Leave the client's room and return later in the day.

Explain that insulin is a life-saving drug for the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.

Choice B rationale:

Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.

Choice C rationale:

Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.

Choice D rationale:

Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.

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Correct Answer is C

Explanation

This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic eﬀect. However, this also means that the client is at a higher risk of developing toxicity or side eﬀects from the medication. The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inﬂammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.

a) Administer a PRN dose of acetaminophen.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Acetaminophen is an analgesic and antipyretic medication that can help reduce pain and fever. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should administer a PRN dose of acetaminophen only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

b) Encourage the client to drink ﬂuids.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking ﬂuids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink ﬂuids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

d) Monitor the client's serum lipid levels.

This is not the priority action by the PN because it is not related to the client's symptoms. Serum lipid levels are measures of fats and cholesterol in the blood, which are important for energy production, hormone synthesis, and cell membrane structure. However, they are not related to inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should monitor the client's serum lipid levels only if they are prescribed a medication that can aﬀect lipid metabolism, such as statins or fibrates.

A. Concerns about parenting. B. Cultural practices related to childbearing. C. Complications associated with childbirth. D. Knowledge about labor and delivery.

Correct Answer is D

Explanation

Choice A rationale:

Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.

Choice B rationale:

Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.

Choice C rationale:

Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.

Choice D rationale:

Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.

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When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room.
Which action should the nurse take?