The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?
"I was monitoring my blood glucose every 3 to 4 hours."
"I had to stop my insulin."
"I called the doctor because of these symptoms."
None of the above.
The Correct Answer is B
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.
Therefore, these are not indications for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.
Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.
Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.
Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.
Correct Answer is C
Explanation
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
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