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Exhibits

Which of the following should the nurse plan to include when providing teaching for the client? Select all that apply.

How to check blood glucose at home

Instructions on how to take metoprolol

Check feet weekly on the same day each week

Manifestations of hyperglycemia and hypoglycemia

Perform 100 min of physical activity per week

Weight loss tips

Answer and Explanation

Correct Answer : A,D,E,F

Rationale for Correct Answers

How to check blood glucose at home: The client has hyperglycemia and may have undiagnosed diabetes. Teaching self-monitoring of blood glucose is essential for ongoing glycemic control, treatment adjustments, and early detection of dangerous fluctuations.
Manifestations of hyperglycemia and hypoglycaemia: The client is already showing signs of hyperglycemia (polyuria, weight loss, fatigue). Understanding the symptoms of both high and low blood sugar helps prevent complications and allows timely self-intervention.
Perform 100 min of physical activity per week: Moderate physical activity helps improve insulin sensitivity and blood glucose regulation. While 150 min/week is ideal, 100 min is a beneficial starting point for clients new to exercise or with complications like foot ulcers.
Weight loss tips: The client has a BMI of 27, which falls into the overweight category. Weight loss is often beneficial for improving blood glucose control in individuals with type 2 diabetes and reducing overall health risks.

Rationale for Incorrect Answers

Instructions on how to take metoprolol: There is no indication in the data that the client has hypertension, arrhythmia, or another condition that warrants beta-blocker therapy. Teaching this would be irrelevant unless metoprolol is newly prescribed.
Check feet weekly on the same day each week: Clients with diabetes or suspected diabetes should be taught to inspect their feet daily, not weekly. Delayed detection of wounds or infection can lead to severe complications, including amputation.

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Correct Answer is B

Explanation

A. Administer digoxin by IV bolus: Digoxin slows conduction through the AV node and can worsen a complete heart block. It is contraindicated in this condition and may lead to further bradycardia or cardiac arrest.
B. Prepare the client for temporary pacing:Third-degree (complete) heart block results in electrical dissociation between atria and ventricles, leading to dangerously low heart rates and inadequate perfusion. The definitive treatment is temporary pacing to stabilize the cardiac rhythm until permanent pacing can be arranged.
C. Instruct the client to perform the Valsalva maneuver: This maneuver is used to terminate supraventricular tachycardias by stimulating the vagus nerve. It is not indicated in bradyarrhythmias like third-degree heart block and could further lower the heart rate.
D. Perform carotid sinus massage: This is another vagal maneuver used to treat tachycardias, not bradycardias. Performing it in a client with third-degree heart block could dangerously reduce the heart rate further and is therefore inappropriate.

A. Excessive urinary output B. Elevated sodium level C. Bounding peripheral pulses D. Hyperactive deep tendon reflexes

Correct Answer is C

Explanation

A. Excessive urinary output: In syndrome of inappropriate antidiuretic hormone (SIADH), there is decreased urinary output, not excessive output. The body retains water due to increased antidiuretic hormone (ADH), leading to fluid retention.

B. Elevated sodium level: Due to excessive water retention and dilution of electrolytes, clients with SIADH typically experience hyponatremia (decreased sodium level), not an elevated sodium level. The retained water dilutes the body's sodium concentration.

C. Bounding peripheral pulses: Bounding peripheral pulses are expected in SIADH due to fluid overload, as the body retains excessive water. This leads to increased blood volume and can cause the peripheral pulses to feel strong or "bounding."

D. Hyperactive deep tendon reflexes: Hyperactive deep tendon reflexes are typically associated with conditions such as hypercalcemia or hyperthyroidism, not SIADH. SIADH is more likely to cause muscle weakness and fatigue due to hyponatremia.

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Exhibits Which of the following should the nurse plan to include when providing teaching for the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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Exhibits

Which of the following should the nurse plan to include when providing teaching for the client? Select all that apply.