A home health nurse is planning an initial home visit for a client who has a new diagnosis of diabetes mellitus. Which of the following interventions should the nurse plan to perform first?
Encourage the client to participate in a diabetes mellitus support group.
Determine the client's level of health literacy.
Verify the client's comfort level regarding how to use a glucometer.
Provide low-carbohydrate recipes for the client.
The Correct Answer is B
A. Encourage the client to participate in a diabetes mellitus support group: While support groups are beneficial for emotional support and ongoing education, this intervention is not the priority during the initial home visit. It is more appropriate once the client’s knowledge and self-care skills have been assessed.
B. Determine the client's level of health literacy: Assessing health literacy is the first priority because it guides the nurse in tailoring education and interventions. Understanding the client’s ability to comprehend and apply health information ensures that teaching about diabetes management, such as glucose monitoring and medication administration, is effective and safe.
C. Verify the client's comfort level regarding how to use a glucometer: Ensuring the client can correctly use a glucometer is important, but this step should follow the assessment of health literacy. Tailoring instruction to the client’s literacy level improves comprehension and accuracy in self-monitoring.
D. Provide low-carbohydrate recipes for the client: Providing dietary resources supports diabetes management but is secondary to assessing the client’s understanding and ability to implement self-care. Without first evaluating literacy and comprehension, these resources may not be effectively utilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationale for correct choices
• Mania: The client exhibits classic signs of mania, including elevated mood, excessive energy, decreased need for sleep, impulsive behavior such as excessive spending, and pressured, disorganized speech. These behaviors are consistent with a manic episode rather than delirium, catatonia, major depressive disorder, or panic disorder.
• Euphoric mood: The client demonstrates an overly joyous and elevated sense of self-confidence, which is characteristic of euphoric mood during a manic episode. Euphoric mood contributes to impulsive behaviors, distractibility, and poor judgment. This finding aligns with the manic episode and helps distinguish mania from other psychiatric conditions that primarily involve negative mood states or anxiety.
Rationale for incorrect choices
• Delirium: Although the client is disoriented to place and exhibits poor concentration, delirium typically develops acutely and fluctuates, often secondary to a medical condition or substance use. The client’s sustained elevated mood, impulsive behavior, and pressured speech are not consistent with delirium.
• Panic disorder: Panic disorder involves sudden episodes of intense fear, palpitations, and autonomic hyperactivity, which are not reported in this client. The client’s persistent elevated mood, lack of fear-driven episodes, and impulsive behaviors do not align with panic disorder symptoms.
• Catatonia: Catatonia is characterized by motor immobility, stupor, mutism, or rigidity, which contrasts sharply with the client’s constant movement, hyperactivity, and pressured speech. The client demonstrates goal-directed and excessive activity rather than the motor inhibition seen in catatonia.
• Major depressive disorder: Major depressive disorder involves persistent low mood, anhedonia, and lack of energy, which is the opposite of the client’s elevated, euphoric mood and hyperactivity. The client’s impulsivity and pressured speech indicate a manic state rather than depression. Depressive symptoms are not evident in the current presentation.
• Magical thinking: Although magical thinking can occur in some psychiatric conditions, the client’s primary feature is euphoric mood and goal-directed hyperactivity. There is no evidence of superstitious beliefs or illogical thought processes driving behavior.
• Alogia: Alogia refers to poverty of speech or reduced verbal output, which is inconsistent with the client’s pressured and loud speech. The client demonstrates excessive verbal output, indicating elevated energy rather than speech poverty.
• Anhedonia: Anhedonia, or lack of pleasure, is a symptom of depression, which is absent here. The client’s enjoyment of activities, desire to host parties, and euphoric mood contradict the presence of anhedonia.
• Hypervigilance: Hypervigilance involves excessive alertness and scanning for threats, often seen in anxiety or PTSD. While the client reports seeing hallucinations, these perceptual disturbances are more consistent with psychosis, not hypervigilance. The primary finding supporting mania is euphoric mood rather than anxiety-driven alertness.
Correct Answer is D
Explanation
A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.
B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.
C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.
D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.
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