A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes
mellitus and reports difficulty following the diet and remembering to take the
prescribed medication.
Which of the following actions should the nurse take to promote client compliance?
(SATA)
A. Ask the dietitian to assist with meal planning
B. Contact the client's support system
C. Assess for age-related cognitive awareness
D. Encourage the use of a daily medication dispenser
E. Provide educational materials for home use
{{ANS- A, B, D, E
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the
basis of this test result, the nurse plans to teach the client about the need for which
measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia
{{ANS- D
RATIONALE:
The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This
test measures the amount of glucose that has become permanently bound to the red
blood cells from circulating glucose. Erythrocytes live for about 120 days, giving
feedback about blood glucose for the past 120 days. Elevations in the blood glucose
level will cause elevations in the amount of glycosylation. Thus, the test is useful in
identifying clients who have periods of hyperglycemia that are undetected in other
ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205
mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching related to the
prevention of hyperglycemic episodes.
The nurse is instructing a client how to perform a testicular self-examination (TSE).
The nurse should explain that which is the best time to perform this exam?
A. After a shower or bath
B. While standing to void
C. After having a bowel movement
D. While lying in bed before arising
{{ANS- A
RATIONALE:
The nurse needs to teach the client how to perform a TSE. The nurse should instruct
the client to perform the exam on the same day each month. The nurse should also
instruct the client that the best time to perform a TSE is after a shower or bath when
the hands are warm and soapy and the scrotum is warm. Palpation is easier and the
client will be better able to identify any abnormalities. The client would stand to
perform the exam, but it would be difficult to perform the exam while voiding. Having
a bowel movement is unrelated to performing a TSE.
The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that apply.
A. Auscultating lung sounds
B. Obtaining the client's temperature
C. Assessing the strength of peripheral pulses
D. Obtaining information about the client's respirations
E. Performing a musculoskeletal and neurological examination
F. Asking the client about a family history of any illness or disease
{{ANS- A, B, D
RATIONALE:
A focused assessment focuses on a limited or short-term problem, such as the client's
complaint. Because the client is complaining of symptoms of a cold, a cough, and lung
congestion, the nurse would focus on the respiratory system and the presence of an
infection. A complete assessment includes a complete health history and physical
examination and forms a baseline database. Assessing the strength of peripheral
pulses relates to a vascular assessment, which is not related to this client's complaints.
A musculoskeletal and neurological examination also is not related to this client's
complaints. However, strength of peripheral pulses and a musculoskeletal and
neurological examination would be included in a complete assessment. Likewise,
asking the client about a family history of any illness or disease would be included in a
complete assessment.
The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral
development with a parent. The nurse should tell the parent that which factor
motivates good and bad actions for the child at the preconventional level?
A. Peer pressure
B. Social pressure
C. Parents' behavior
D. Punishment and reward
{{ANS- D
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