Priority Decision: The nurse is assessing a newly admitted diabetic patient. Which observation should be addressed as the priority by the nurse?

Correct Answer: C

Rationale: In this scenario, the priority observation that the nurse should address is option C) Stage II pressure ulcer on the right heel. Rationale for correct answer: This finding is the priority because pressure ulcers can lead to serious complications, such as infections, if not managed promptly. In diabetic patients, impaired circulation and sensation increase the risk of pressure ulcer development and delay wound healing. Therefore, addressing the pressure ulcer promptly is crucial to prevent further deterioration of the patient's condition. Rationale for incorrect answers: A) Bilateral numbness of both hands: While numbness is a common symptom in diabetic patients due to neuropathy, it is not an immediate threat to the patient's well-being compared to a pressure ulcer. B) Rapid respirations with deep inspiration: This may indicate respiratory distress or another underlying issue, but it is not directly related to the patient's diabetic condition or as urgent as managing a pressure ulcer. D) Areas of lumps and dents on the abdomen: This finding could be related to lipohypertrophy from insulin injections, which can affect insulin absorption but is not as urgent as addressing a pressure ulcer. Educational context: Understanding the priority of patient assessments is crucial for nurses to provide effective and timely care. In diabetic patients, vigilance in assessing for complications like pressure ulcers is essential to prevent further health issues. This scenario highlights the significance of recognizing urgent versus non-urgent observations in clinical practice and prioritizing interventions based on patient needs.

Correct Answer: D

Rationale: The correct answer is D) In genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion. Rationale: Graves' disease is an autoimmune disorder where the body's immune system mistakenly targets the thyroid gland, leading to the production of antibodies that stimulate the thyroid to produce excessive amounts of thyroid hormones. This overproduction of thyroid hormones results in symptoms such as weight loss, rapid heartbeat, and heat intolerance. Option A is incorrect because while there may be a genetic component to Graves' disease, it is not solely attributed to genetics. Option B is incorrect as Graves' disease is not caused by an iodine deficiency. Option C is incorrect as it describes the mechanism of Hashimoto's thyroiditis, where antibodies attack the thyroid gland leading to a deficiency of thyroid hormones. Educational Context: Understanding the etiology of Graves' disease is crucial for healthcare professionals to provide accurate information to patients and offer appropriate care. By knowing that it is an autoimmune condition involving the production of stimulating antibodies against the thyroid gland, nurses can better educate patients on the management and treatment options available. This knowledge also helps in early identification of symptoms and prompt intervention to prevent complications associated with excessive thyroid hormone secretion.

Correct Answer: A

Rationale: In Cushing syndrome, the body is exposed to high levels of cortisol over a prolonged period, leading to characteristic signs and symptoms. The correct answer is A) Hypertension, peripheral edema, and petechiae. Hypertension is common due to cortisol's role in fluid and electrolyte balance. Peripheral edema results from sodium retention and increased capillary permeability. Petechiae may occur due to fragile capillaries from cortisol-induced skin changes. Option B is incorrect as weight gain, not loss, is typical in Cushing syndrome. Buffalo hump and moon face are due to fat redistribution, not acne. Option C is incorrect as truncal obesity and striae are expected, not hypotension. Option D is incorrect as hyperpigmentation, anorexia, and dehydration are more indicative of Addison's disease, not Cushing syndrome. Educationally, understanding these specific manifestations of Cushing syndrome aids nurses in recognizing and managing patients with this condition effectively. It emphasizes the importance of differentiating between various endocrine disorders based on clinical presentations for accurate diagnosis and treatment.

Correct Answer: C

Rationale: In this question, the correct answer is option C) regular insulin. Regular insulin is the only type that can be safely administered intravenously. This is because regular insulin has a fast onset of action, making it suitable for intravenous use to quickly lower blood glucose levels in emergency situations such as diabetic ketoacidosis or hyperglycemic crises. Option A) Lente insulin and option B) Semi-Lente insulin are both long-acting insulins that are designed for subcutaneous administration and have a slower onset of action compared to regular insulin. Administering these types intravenously can lead to erratic absorption and potentially dangerous fluctuations in blood glucose levels. Option D) NPH insulin is an intermediate-acting insulin that is also meant for subcutaneous administration. Using NPH insulin intravenously can result in unpredictable absorption patterns and is not recommended due to the risk of hypoglycemia or hyperglycemia. From an educational standpoint, understanding the different types of insulin and their appropriate routes of administration is crucial for healthcare professionals, especially those working in settings where intravenous insulin administration may be necessary. Proper knowledge of insulin types and their characteristics helps ensure safe and effective management of diabetes and related conditions.

Correct Answer: B

Rationale: The correct answer is B) corns. Corns are areas of thickened skin that develop on the feet due to excessive pressure or friction, common in individuals with diabetes. By observing for the presence of corns on the patient's feet during the next visit, the nurse can assess whether the patient is following the foot care instructions provided. Corns indicate that there is still excessive pressure or friction on certain areas of the feet, suggesting that the patient may not be implementing the recommended foot care practices effectively. Option A) colored socks is incorrect as the color of the socks does not provide any direct indication of the patient's foot care practices or diabetic management. Option C) straight toenails is incorrect as well because while proper nail care is important for diabetic patients, it is not the most reliable indicator of the effectiveness of foot care teaching. Option D) dermatophytosis is a fungal infection that can affect the feet, but it is not directly related to the effectiveness of the foot care teaching provided by the nurse. In an educational context, understanding the significance of assessing foot health in diabetic patients is crucial. Poor foot care can lead to serious complications such as ulcers and infections, which can result in amputations. Nurses play a vital role in educating diabetic patients on proper foot care practices to prevent such complications. By evaluating the outcomes of their teaching, nurses can tailor their education to meet the specific needs of each patient and promote better health outcomes.