Question

Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

Answer 1

Correct Answers:

Assess the patient’s perception of what it means to have type 2 diabetes.

Rationale :

🩺The first step in patient education is always to assess the patient’s current knowledge and perception of the illness.

🧩This establishes a baseline understanding, ensuring that the education is tailored to the patient’s needs.

📚Jumping into teaching without assessment risks information overload or irrelevance to the patient’s concerns.

💡By assessing perception first, the nurse can provide individualized, effective education that promotes engagement.

📌Core Message

The nurse should first assess the patient’s perception to provide individualized diabetes education effectively.

Answer 2

Correct Answers:

chicken leg, one slice of bread with butter, and steamed carrots

Rationale :

🥗This option reflects a low-sodium meal, as fresh chicken and vegetables contain minimal added sodium compared to processed foods.

🥓Ham and cheese are processed foods, both high in sodium content, making them inappropriate for restriction.

🥡Chinese take-out and soups often contain excess sodium, which should be avoided on a sodium-restricted diet.

🍞Therefore, the chosen meal demonstrates that the client has understood dietary teaching.

📌Core Message

Clients on sodium restriction should select fresh, minimally processed foods like chicken and vegetables.

Answer 3

Correct Answers:

“I had the stomach ﬂu earlier this week and couldn't take the hydrocortisone.”

Rationale :

💊Patients with Addison’s disease require consistent corticosteroid replacement to prevent adrenal crisis.

🤢Illness or stress often requires increased doses, not skipping, because the body cannot make additional cortisol.

⚠️Omitting the dose during illness is dangerous and is a common cause of Addisonian crisis.

📖This shows a lack of knowledge in self-management, supporting the nursing diagnosis of ineffective therapeutic regimen management.

📌Core Message

Patients with Addison’s disease must never skip hydrocortisone, especially during illness or stress.

Answer 4

Correct Answers:

Breath sounds.

Rationale :

🌬️A stroke patient who is unconscious is at high risk of aspiration due to impaired swallowing and protective reflexes.

💁‍♂️Assessing breath sounds helps detect early signs of aspiration pneumonia or airway compromise.

🍽️A history of GERD increases the risk of gastric contents entering the lungs when consciousness is reduced.

🚨Therefore, monitoring airway and respiratory status is the nurse’s priority.

📌Core Message

For an unconscious stroke patient with GERD, the priority is monitoring breath sounds for aspiration risk.

Answer 5

Correct Answers:

You will need to keep the head of your bed elevated on blocks.

Rationale :

🛏️Elevating the head of bed reduces reflux episodes by preventing gastric contents from moving upward.

🍵Peppermint actually worsens reflux, so it should be avoided.

🍽️Avoiding meals is not appropriate; instead, smaller frequent meals are better.

🏃Vigorous exercise can increase reflux but is not the primary teaching priority like bed elevation.

📌Core Message

The most effective lifestyle teaching for GERD is elevating the head of the bed to reduce reflux.

Answer 6

Correct Answers:

Prevent transmission of infection.

Rationale :

🧴Operating room design prioritizes infection control to protect patients undergoing surgery.

🚪Traffic control reduces contamination risk, which could compromise sterile procedures.

🩺Although efficiency and teamwork are important, sterility and infection prevention take precedence.

🛡️Thus, the main goal of OR environmental control is to prevent surgical site infections.

📌Core Message

The operating room environment is structured to prevent infection transmission during surgery.

Answer 7

Correct Answers:

Do not stop taking the prednisone suddenly, it should be decreased gradually.

Rationale :

💊Long-term corticosteroid therapy suppresses the adrenal glands.

🛑Stopping abruptly can trigger acute adrenal insufficiency, a life-threatening condition.

⚖️Gradual tapering allows the adrenal glands to recover function and prevents crisis.

📚This is the most important teaching for safe use of prednisone therapy.

📌Core Message

Prednisone must be tapered gradually to prevent adrenal insufficiency.

Answer 8

Correct Answers:

Teach the patient how to perform Kegel exercises.

Rationale :

💧The patient’s report of urine leakage with laughing or coughing indicates stress incontinence.

🏋️Kegel exercises strengthen the pelvic floor muscles, reducing leakage episodes.

🚽Scheduled toileting or bedside commodes are not appropriate for this type of incontinence.

📖Crede’s maneuver is for neurogenic bladder, not stress incontinence.

📌Core Message

For stress incontinence, the best intervention is teaching Kegel exercises.

Answer 9

Correct Answers:

2.9 mEq/L

Rationale :

⚡Furosemide is a potassium-wasting diuretic, increasing risk of hypokalemia.

🧠Low potassium (<3.5 mEq/L) can cause confusion, weakness, and arrhythmias.

📉A potassium level of 2.9 mEq/L confirms significant hypokalemia as the cause of confusion.

🧪Normal potassium is 3.5–5.0 mEq/L, so other values listed are not abnormal.

📌Core Message

Hypokalemia (2.9 mEq/L) from furosemide use causes confusion and complications.

Answer 10

Correct Answers:

“Do you ever have any chest pain?”

Rationale :

❤️Graves’ disease causes hyperthyroidism, which increases cardiac workload.

📈Findings like bounding pulse and hypertension suggest strain on the cardiovascular system.

⚠️Chest pain could indicate angina or cardiac complications, making this the most important assessment.

🩺Other options are less directly linked to the acute cardiovascular risks of hyperthyroidism.

📌Core Message

In Graves’ disease, cardiac assessment for chest pain is essential due to cardiac strain.

1 :
Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

2 :
A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been eﬀective?

3 :
A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

4 :
When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

5 :
Which information will the nurse include when teaching a patient with newly diagnosed GERD?

6 :
The physical environment and traffic control measures of the operating room are designed primarily to:

7 :
A patient is taking high doses of prednisone to control the symptoms of acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is important for the nurse to include?

8 :
After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

9 :
A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

10 :
During the nursing assessment of a patient with Graves' disease, the nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?

1 : Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

2 : A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been eﬀective?

3 : A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

4 : When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

5 : Which information will the nurse include when teaching a patient with newly diagnosed GERD?

6 : The physical environment and traffic control measures of the operating room are designed primarily to:

7 : A patient is taking high doses of prednisone to control the symptoms of acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is important for the nurse to include?

8 : After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

9 : A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

10 : During the nursing assessment of a patient with Graves' disease, the nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?

1 :
Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

2 :
A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been eﬀective?

3 :
A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

4 :
When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

5 :
Which information will the nurse include when teaching a patient with newly diagnosed GERD?

6 :
The physical environment and traffic control measures of the operating room are designed primarily to:

7 :
A patient is taking high doses of prednisone to control the symptoms of acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is important for the nurse to include?

8 :
After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

9 :
A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

10 :
During the nursing assessment of a patient with Graves' disease, the nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?