A client newly diagnosed with type 2 diabetes mellitus has a nursing diagnosis of Knowledge deficit: diabetes, medical regimen, diet, exercise, and self-care management skills. Which nursing goal is appropriate for this client?

to use the food pyramid for meal planning

to relate importance of an exercise program

to maintain current weight

to maintain vital signs within normal limits

Answer and Explanation

The Correct Answer is B

A. To use the food pyramid for meal planning: The food pyramid may not be the most relevant tool in nutrition education. Often used are more detailed, individualized approaches like carb counting or plate method. This goal doesn’t address the client’s knowledge deficit.

B. To relate importance of an exercise program: An essential aspect of diabetes management is understanding the role of exercise in controlling blood glucose levels. This goal addresses the client’s need for knowledge about exercise as part of diabetes management.

C. To maintain current weight: While maintaining a healthy weight is important, this goal does not fully address the knowledge deficit about the client’s medical regimen, diet, and self-care management. It is more of an outcome rather than an educational goal.

D. To maintain vital signs within normal limits: Maintaining normal vital signs is important for overall health, but this goal does not directly relate to the client's understanding of how to manage their diabetes.

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Correct Answer is C

Explanation

A. Check for Asterixis: Asterixis, also known as flapping tremor, is typically associated with hepatic encephalopathy or liver failure, not thyroidectomy. Therefore, it is not an immediate concern for a client following a subtotal thyroidectomy.

B. Place the client in a side-lying position: There is no specific need to place the patient in a side-lying position post-thyroidectomy. The semi-Fowler's position is more commonly used to promote breathing and reduce pressure on the neck.

C. Check for bleeding at the back of the client's neck: Bleeding at the back of the neck or around the incision site is a critical concern after a thyroidectomy, as it can lead to airway obstruction or hematoma formation. The nurse should frequently assess the surgical site for signs of bleeding and hematoma formation.

D. Ensure that acetylcysteine IV is readily available: Acetylcysteine (Mucomyst) is typically used for acetaminophen toxicity or to treat mucous secretions, not for complications related to thyroidectomy.

A. prevent diabetic coma B. improve nutrition C. improve carbohydrate metabolism D. prevent an insulin reaction

Correct Answer is D

Explanation

A. Prevent diabetic coma: A diabetic coma (such as diabetic ketoacidosis or hyperosmolar hyperglycemic state) is not the primary concern related to insulin administration. It is associated with severe hyperglycemia, not with the need for a snack to balance insulin action.

B. Improve nutrition: While the snack may help with overall nutrition, it is not primarily intended to improve nutrition in this scenario. The goal is to maintain blood sugar levels within a safe range, particularly after insulin administration.

C. Improve carbohydrate metabolism: The primary goal of the mid-afternoon snack is not to directly impact carbohydrate metabolism. The snack is designed to maintain glucose levels after insulin has been administered.

D. Prevent an insulin reaction: The snack is likely provided to prevent hypoglycemia or an insulin reaction (low blood sugar). Humulin N insulin is an intermediate-acting insulin, and its peak action occurs several hours after administration. The snack helps prevent low blood sugar by providing a source of glucose to balance the insulin effect.

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A client newly diagnosed with type 2 diabetes mellitus has a nursing diagnosis of Knowledge deficit: diabetes, medical regimen, diet, exercise, and self-care management skills. Which nursing goal is appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

Correct Answer is C

Explanation

The physician orders a 1,800-calorie diabetic diet and 40 units of Humulin N insulin (an intermediate-acting insulin) administered subcutaneously @ 0700 for a patient with diabetes mellitus. A mid-afternoon snack of milk and crackers is given to

Correct Answer is D

Explanation

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