The nurse is conducting discharge teaching with a client who has been newly diagnosed with type 1 diabetes mellitus. Which statement from the client indicates the need for additional teaching?

As long as I’m in my house, I can walk barefoot

It is important to test my blood sugar at least four times a day

I need to be alert for infections

I need to stay hydrated during the day

Answer and Explanation

The Correct Answer is A

Choice A reason: Walking barefoot, even at home, is risky for type 1 diabetes patients due to neuropathy, which reduces foot sensation, increasing injury risk. Unnoticed cuts can lead to infections, exacerbated by poor healing from hyperglycemia, indicating a need for further education on foot care.

Choice B reason: Testing blood sugar at least four times daily is correct for type 1 diabetes to monitor glucose levels and adjust insulin. This reflects proper self-management, aligning with standard care guidelines, so no additional teaching is needed for this statement.

Choice C reason: Being alert for infections is critical in type 1 diabetes, as hyperglycemia impairs immune function, increasing infection risk. This statement shows appropriate awareness of complications, consistent with proper self-care, so no further teaching is required.

Choice D reason: Staying hydrated is important in type 1 diabetes to prevent dehydration from polyuria, a common symptom due to glucose-induced osmotic diuresis. This statement indicates correct understanding, aligning with management goals, so no additional teaching is needed.

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Correct Answer is C

Explanation

Choice A reason: Hallucinations involve false sensory perceptions, like hearing voices or seeing things. The client’s nonsensical statement reflects disorganized thinking, not sensory experiences, making this choice incorrect for the described manifestation of schizophrenia.

Choice B reason: Anhedonia is the loss of pleasure in activities, a negative symptom of schizophrenia. The client’s statement reflects disorganized speech, not lack of enjoyment, making this choice incorrect for the specific manifestation described.

Choice C reason: Loose associations, a hallmark of acute schizophrenia, involve disorganized speech where thoughts are loosely connected, as in the client’s incoherent statement. This reflects disrupted thought processes due to altered neural pathways, making this the correct choice.

Choice D reason: Delusional disorder involves fixed false beliefs, not disorganized speech. The client’s statement is nonsensical, indicating loose associations rather than a specific delusional belief, making this choice incorrect for the manifestation.

A. Ensuring proper fit of the brace B. How patient sleeps with the brace on C. Monitor patient breathing D. Patient education and family about the brace’s purpose and care E. Skin integrity

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Ensuring proper fit of the TLSO is critical to stabilize the spine effectively, preventing further injury. An ill-fitting brace can cause misalignment, pressure sores, or reduced efficacy, as it fails to immobilize the thoracolumbar region, making this a key nursing priority.

Choice B reason: How the patient sleeps with the brace is not a primary nursing priority. While comfort during sleep matters, the TLSO is typically worn as prescribed, and sleep position is secondary to ensuring fit, breathing, education, and skin care, making this choice incorrect.

Choice C reason: Monitoring breathing is essential, as a TLSO can restrict chest expansion, potentially reducing tidal volume and causing respiratory distress. Nurses must assess respiratory rate and oxygen saturation to ensure the brace does not compromise ventilation, making this a critical priority.

Choice D reason: Educating the patient and family about the TLSO’s purpose and care ensures compliance and proper use. Understanding how to wear, clean, and adjust the brace prevents complications like skin breakdown or ineffective stabilization, making this a key nursing responsibility.

Choice E reason: Skin integrity is a priority, as prolonged brace use can cause pressure ulcers or irritation. Nurses must inspect skin under the TLSO regularly, ensuring proper padding and hygiene to prevent breakdown, especially in immobile patients, making this a critical care aspect.

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The nurse is conducting discharge teaching with a client who has been newly diagnosed with type 1 diabetes mellitus. Which statement from the client indicates the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, “Yesterday noon the sun moon went over the rover to see the lawnmower.” Which of the following manifestations is the client exhibiting?

Correct Answer is C

Explanation

A patient has a new order for a thoraco-lumbo-sacral orthosis (TLSO) to help support and stabilize her spine. What are the nursing priorities when caring for this patient? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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