The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client?
The nurse will monitor the client's blood glucose levels four (4) times a day.
The client will demonstrate appropriate insulin injection techniques
The client will maintain normal kidney function with 30-ml/hr urine output.
The client will have a blood glucose level between 60-110 mg/dl at 1600.
The Correct Answer is D
A. The nurse will monitor the client's blood glucose levels four (4) times a day: This is important, but it is an intervention rather than a goal. A goal should be measurable and focused on the client's outcome, such as maintaining specific glucose levels.
B. The client will demonstrate appropriate insulin injection techniques: This is a good educational goal, but it does not directly address the immediate concern. The problem states noncompliance, implying the client knows how to inject but isn't doing it consistently.
C. The client will maintain normal kidney function with 30-ml/hr urine output: While monitoring kidney function is important in diabetes, this goal does not address the immediate risk of hyperglycemia. Urine output is not the primary indicator of hyperglycemia.
D. The client will have a blood glucose level between 60-110 mg/dl at 1600: This short-term goal is specific, measurable, and time-bound. It addresses the desired outcome of maintaining blood glucose within a normal range, which addresses hyperglycemia due to noncompliance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the night supervisor of the patient's deteriorating condition: While it’s important to keep supervisors informed, hypoglycemia needs to be treated immediately. The priority action is to raise the patient’s blood glucose level, not waiting to notify the supervisor.
B. The patient is experiencing symptoms of hypoglycemia, and the best initial action is to give a fast-acting carbohydrate like orange juice (about 15g of sugar). After 15 minutes, the blood sugar should be rechecked. Following the treatment with a complex carbohydrate and protein helps to maintain blood glucose levels and prevent recurrence of hypoglycemia.
C. Ambulate the patient in the hall to use up excess glucose with exercise: Exercise can lower blood glucose levels, which would be dangerous in a hypoglycemic patient. The priority is to raise the blood sugar rather than use exercise to manage glucose levels.
D. Give insulin by sliding scale based on glucometer reading: The patient’s blood sugar is low (51 mg/dL), which indicates hypoglycemia, not hyperglycemia. Insulin should not be administered in this situation, as it would further decrease the blood glucose levels.
Correct Answer is D
Explanation
A. "This test detects antithyroid antibodies in your blood.": While antithyroid antibodies are measured in some thyroid disorders (like Hashimoto's thyroiditis), the TSH test specifically measures the level of thyroid-stimulating hormone produced by the pituitary gland.
B. "This test measures the amount of thyroid hormone that attaches to a protein in your blood.": TSH levels do not measure thyroid hormone bound to proteins; rather, TSH is a hormone produced by the pituitary gland that regulates the production of thyroid hormones.
C. "This test measures the absorption of iodine and how it relates to the thyroid gland.": The TSH test does not measure iodine absorption. A radioactive iodine uptake test is used for assessing iodine absorption by the thyroid gland.
D. "The test determines whether your thyroid gland is overactive, appropriately active, or underactive.": The TSH test is used to assess thyroid function. The test helps determine whether the thyroid is working appropriately or if there is a dysfunction.
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