The home health nurse is visiting a client with diabetes mellitus, type 2 who reports nausea and vomiting for the past 3 days and not taking prescribed insulin because of the inability to "keep food down." Which of the following responses would be most appropriate for the nurse to make?

"Continue taking your usual insulin dose even if you have nausea and vomiting."

"Check your blood sugar level twice each day even if you are not eating."

"Avoid drinking soda or fruit juices because it will increase your blood sugar level."

"Limit your daily fluid intake as it may aggravate your nausea and vomiting.

Answer and Explanation

The Correct Answer is A

A. It is important for the client with diabetes to continue taking their insulin as prescribed, even if they are unable to eat. When the body is under stress (e.g., due to illness), blood sugar levels can rise, and insulin is still necessary to manage glucose levels. Skipping insulin could lead to hyperglycemia or diabetic ketoacidosis (DKA), which can be life-threatening. The nurse should encourage the client to continue insulin therapy and consider alternative ways to manage nausea (e.g., antiemetics).
B. While it is important for the client to monitor their blood glucose, checking it twice a day may not be sufficient during illness. The client should check their blood glucose more frequently (e.g., every 4 hours) to avoid the risk of hyperglycemia or DKA, especially if they are not eating or drinking regularly.
C. When a person with diabetes is ill and unable to eat, it is important to ensure they stay hydrated and maintain glucose levels. Clear liquids such as soda or fruit juice may help with hydration and provide a quick source of sugar if the blood glucose drops too low, though they should be consumed in moderation.
D. It is essential for the client to stay hydrated, especially if they are vomiting. Dehydration can worsen blood sugar control and lead to further complications. The client should be encouraged to drink small, frequent sips of water or electrolyte solutions to stay hydrated.

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Correct Answer is C

Explanation

A. Alcohol withdrawal is a known risk factor for seizures. It can lead to withdrawal seizures, especially if the client has been drinking heavily and abruptly stops or reduces alcohol consumption.
B. A genetic predisposition can increase the risk of seizures. Certain genetic conditions, such as epilepsy, can increase the likelihood of experiencing seizures.
C. Tension headaches are not typically considered a risk factor for seizures. While headache disorders like migraines can sometimes be associated with seizures, tension headaches are generally not linked to an increased risk of seizure activity.
D. Prolonged hypoxemia (low oxygen levels) can lead to brain injury and is a well-established risk factor for seizures. When the brain does not receive enough oxygen, it can trigger seizure activity.
E. Older adults are at a higher risk for seizures, often due to conditions such as stroke, brain tumors, or age-related changes in the brain that can affect electrical activity.

A. "I will use the first drop of blood for my sample" B. "I will poke in the center of the pad of my finger to obtain a sample for testing" C. "I will apply a cold compress on my fingers if I cannot collect any blood" D. "I will make sure I have clean hands prior to testing"

Correct Answer is D

Explanation

A. It is generally recommended to discard the first drop of blood when testing with a glucometer because it may be diluted with tissue fluid, leading to inaccurate results. The second drop should be used for the sample.
B. The center of the fingertip should be avoided for testing because it contains more nerve endings and can be more painful. It is better to poke the sides of the fingertip for a less painful experience.
C. A cold compress may cause blood vessels to constrict, making it even harder to obtain a blood sample. Gentle massaging of the finger or warming the hands may help with blood flow.
D. It is important to wash hands before testing to ensure that the blood sample is not contaminated with food residues, dirt, or other substances that could affect the accuracy of the glucose reading.

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The home health nurse is visiting a client with diabetes mellitus, type 2 who reports nausea and vomiting for the past 3 days and not taking prescribed insulin because of the inability to "keep food down." Which of the following responses would be most appropriate for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who experienced a seizure. The nurse knows which of the following is NOT a risk factors for seizure activity?

Correct Answer is C

Explanation

The nurse is educating a newly diagnosed diabetic client about how to measure blood glucose with a glucometer at home. Which statement, made by the client, indicates teaching was effective?

Correct Answer is D

Explanation

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