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 D
Explanation
Validation. Validation is a therapeutic technique that involves acknowledging and accepting the feelings and emotions of the person with dementia, even if they are not based on reality. Validation helps to reduce agitation and anxiety and promotes dignity and respect.
The other choices are not correct for the following reasons:
Remotivation is a technique that aims to stimulate the person's interest in the present and future, by providing factual information and encouraging participation in activities. Remotivation may not be appropriate for someone who is agitated and living in the past.
Orientation to reality is a technique that involves correcting the person's misperceptions and confusions, by providing factual information about time, place, and identity. Orientation to reality may increase agitation and frustration and may damage the person's self-esteem.
Guided imagery is a technique that involves using mental images to promote relaxation and well-being. Guided imagery may not be effective for someone who has difficulty with attention, concentration and memory.
Correct Answer is A
Explanation
Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline.
Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.
Choice B, "This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
Choice C, "I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
Choice D, "This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.
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