A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

"I must restrict my fluid intake."

"I must avoid deep breathing exercises."

"I must lie flat for 48 hours after surgery."

"I must avoid blowing my nose and bending at the waist."

Answer and Explanation

The Correct Answer is D

A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.

B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.

C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.

D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.

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Correct Answer is A

Explanation

A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.

B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.

C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.

D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.

A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.

Exhibits


Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.

Actions to Take:

Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.

Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.

Parameters to Monitor:

Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.

Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.

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A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

A client is receiving desmopressin intranasally. Which assessment parameters would the nurse monitor to determine the effectiveness of this medication?

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