A nurse is teaching an older adult client who has diabetes mellitus about preventing the long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Have an eye examination once per year

Examine your feet carefully every day

Wear compression stockings

"Maintain stable blood glucose level

Answer and Explanation

The Correct Answer is A

A. Have an eye examination once per year - Regular eye examinations are crucial for detecting and managing retinopathy, a complication of diabetes that affects the eyes.

B. Examine your feet carefully every day - Daily foot examinations are essential to detect any early signs of foot problems, which is particularly important in preventing complications like nephropathy.

C. Wear compression stockings - Compression stockings are not directly related to preventing retinopathy and nephropathy in diabetes. They are more commonly used to improve blood flow in the legs.

D. "Maintain stable blood glucose levels" - While maintaining stable blood glucose levels is important for overall diabetes management, it is not specific to preventing retinopathy and nephropathy. It is a general principle for managing diabetes.

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Correct Answer is B

Explanation

A. Obtaining a culture of the drainage may be necessary, but the immediate concern is to determine if the drainage is cerebrospinal fluid (CSF) or another type of fluid. Checking for glucose content is a rapid way to differentiate CSF from other fluids.

B. Correct. Clear drainage from the nose post-transsphenoidal hypophysectomy may indicate a CSF leak, which is a potential complication. Checking the drainage for glucose can help differentiate CSF from other fluids, as CSF contains glucose. If the drainage tests positive for glucose, it indicates the presence of CSF.

C. Documenting the amount of drainage is important, but determining the nature of the drainage (CSF or other fluid) takes precedence in this situation.

D. Notifying the client's provider is important, but the nurse should gather information about the drainage first by checking for glucose content. This information will be crucial for the healthcare provider to make decisions about further interventions

A. Flaccid muscles B. Client report of anorexia C. Client report of numbness in his hands D. Negative Chvostek's sign

Correct Answer is C

Explanation

A. Flaccid muscles are associated with conditions like hypokalemia, not hypoparathyroidism. In hypoparathyroidism, there is a deficiency of parathyroid hormone (PTH), which leads to low calcium levels and can result in muscle spasms and tetany, not flaccid muscles.

B. While anorexia can occur in clients with various health conditions, it is not a specific finding associated with hypoparathyroidism.

C. Correct. Hypoparathyroidism is characterized by low levels of parathyroid hormone (PTH), which leads to low calcium levels in the blood. This can cause symptoms such as numbness, tingling, and muscle cramps, especially in the extremities.

D. A positive Chvostek's sign is associated with hypocalcemia, which can be caused by hypoparathyroidism. Therefore, a negative Chvostek's sign would not be an expected finding in a client with hypoparathyroidism.

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A nurse is teaching an older adult client who has diabetes mellitus about preventing the long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Nursing Test Bank

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