The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?

"Would you like to talk about what is bothering you?"

"Do you feel like practicing insulin injections now?"

"I know you are afraid, but I am here to help you."

"Before you can go home you must learn how to give insulin."

Answer and Explanation

The Correct Answer is A

A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.

B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.

C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.

D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.

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Correct Answer is A

Explanation

A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.

B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.

C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.

D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.

A. Teach the client to rotate the meal plate to visualize all the food on the plate. B. Instruct the client to lift the left extremities with the right hand when transferring. C. Implement precautions when the client is judging distances during transfers. D. Encourage the client to touch, wash, look at, and dress the affected side first.

Correct Answer is C

Explanation

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

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The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is A

Explanation

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

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