A nurse is teaching a patient with a new diagnosis of diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?

Correct Answer: C

Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale: 1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications. 2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective. 3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers. 4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. This is crucial post-total hip replacement to prevent complications such as blood clots, pneumonia, and muscle weakness. Early ambulation helps improve circulation, prevent stiffness, and promote faster recovery. Monitoring for infection (A) is important but not the top priority. Administering pain medications (C) and wound care (D) are essential but do not address the primary goal of preventing complications post-operatively.

Correct Answer: A

Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer. Explanation: 1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s. 2. It encourages self-awareness and early detection of abnormalities in the testicles. 3. Testicular cancer is most common in younger men, making this question relevant. 4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.

Correct Answer: C

Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia. Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level. Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes. Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. In end-stage renal disease, the kidneys are no longer able to regulate blood pressure effectively, leading to hypertension. This can increase the risk of cardiovascular complications. Monitoring for hypertension is crucial in these patients. Rationale for why the other choices are incorrect: B: Hyperglycemia is more commonly associated with diabetes rather than end-stage renal disease. C: Hypothyroidism is a separate condition not directly related to end-stage renal disease. D: Hypokalemia may occur in some cases of renal disease, but hypertension is a more common and critical concern in end-stage renal disease.

Correct Answer: A

Rationale: The correct answer is A: Ear. Examining the ear first is crucial in infants as it allows the nurse to assess for any signs of infection or abnormalities that could impact the infant's overall health. Ear infections are common in infants and can lead to serious complications if not detected early. By examining the ear first, the nurse can promptly address any issues and provide appropriate treatment. Summary of why other choices are incorrect: - B: Nose - While examining the nose is important, it is not the priority in infants as ear issues are more common and can have immediate implications on health. - C: Throat - Throat examination is important but typically follows ear examination in infants, as ear infections are more prevalent. - D: Abdomen - Abdominal examination is important for overall health assessment but is not the initial area to examine in infants as ear issues take precedence due to their frequency and potential impact.

Correct Answer: D

Rationale: The correct answer is D because a proficient nurse should have a holistic view of the patient's situation, focusing on long-term goals rather than just completing tasks. This approach ensures comprehensive care and better outcomes. Choice A is incorrect as it implies reliance on rules over experience. Choice B is incorrect because intuition alone may not always lead to the best solution. Choice C is incorrect as it emphasizes daily plans rather than long-term goals.

Correct Answer: A

Rationale: The correct answer is A. A blood pressure reading of 160/100 mm Hg is most concerning because it falls within the hypertensive crisis range, indicating severely elevated blood pressure that requires immediate medical attention to prevent complications like stroke or heart attack. Choices B, C, and D are within the prehypertension or mild hypertension ranges and are not as immediately concerning.