Patient Data

Exhibits

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

Answer and Explanation

The Correct Answer is []

Potential condition: Retinopathy

Actions to take: Orient the client to the environment; Call for an ophthalmological exam

Parameters to monitor: Blood glucose; Visual acuity

Rationale:

Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.

The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.

Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.

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Correct Answer is B

Explanation

A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.

B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.

C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.

D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.

A. Eat a bland diet and avoid spicy foods. B. Have small frequent meals and sit up for at least two hours after meals. C. Eat a soft diet with increased intake of milk and milk products. D. Eat a high fiber diet and increase fluid intake.

Correct Answer is D

Explanation

A. Eating a bland diet and avoiding spicy foods are not specific recommendations for diverticulosis management. They may be applicable for other gastrointestinal conditions.

B. Having small frequent meals and sitting up after meals are general dietary recommendations for digestive health but are not specific to diverticulosis management.

C. Eating a soft diet with increased intake of milk and milk products may not be suitable for diverticulosis management, especially if lactose intolerance is present. Additionally, a soft diet may lack sufficient fiber.

D. Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis. High-fiber foods help promote regular bowel movements and prevent constipation, which can exacerbate diverticulosis.

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Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Correct Answer is B

Explanation

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Correct Answer is D

Explanation

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Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

Patient Data

Exhibits

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