The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to independently perform fingerstick blood sugar analysis as part of the plan of care. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." Which is the best action by the nurse based on the client's statement?

Correct Answer: D

Rationale: While it is positive that the client has taken the initiative to research the procedure online, it is essential for the nurse to assess the client's actual understanding and ability to perform the fingerstick blood sugar analysis correctly. The best course of action would be for the nurse to watch the client perform a return demonstration of the skill. This will allow the nurse to provide real-time feedback, correct any errors, and ensure that the client is performing the procedure accurately and safely. Watching a return demonstration is a critical step in the client's learning process, as it confirms their comprehension and ability to apply the information effectively. It also enables the nurse to address any misconceptions or gaps in knowledge that may not have been evident from the client's statement alone.

Correct Answer: B

Rationale: Congenital defects are categorized according to the pathophysiology and hemodynamics of the defect. This means that defects are grouped based on the underlying mechanisms that lead to the defect and how these abnormalities impact the flow of blood or other bodily functions. This classification allows healthcare providers to better understand the nature of the defect and tailor treatment plans accordingly. It helps in determining the best course of action, whether it be medical management, surgical intervention, or monitoring for potential complications. By categorizing congenital defects in this way, healthcare providers can provide more targeted and effective care for affected individuals.

Correct Answer: D

Rationale: In older adults, particularly those over 65 years of age, atypical symptoms of a myocardial infarction may occur. Abdominal pain is considered an atypical age-related warning sign because older adults may present with subtle or nonspecific symptoms, such as discomfort or pain in the abdomen, rather than the classic chest pain associated with a heart attack. This atypical presentation can lead to delays in seeking medical attention and diagnosis, which can have serious consequences for the client. Therefore, it is important for the nurse to educate older clients about the possibility of experiencing atypical symptoms, such as abdominal pain, in the context of a myocardial infarction.

Correct Answer: C

Rationale: In disseminated intravascular coagulation (DIC), the client is experiencing joint pain due to the formation of microthrombi which can lead to ischemia and inflammation within the joints. Heat application is appropriate as it can help improve circulation, reduce pain, and promote relaxation of the joints. Heat helps to increase blood flow to the affected area, which can aid in reducing pain and stiffness in the joints. Additionally, heat can also help to soothe the inflamed tissues and promote comfort for the client. Splints, cool compresses, and ice are not appropriate interventions for joint pain in DIC and may not provide the same level of relief as heat therapy.

Correct Answer: B

Rationale: When addressing a client's non-adherence to treatment, a nonjudgmental approach is most effective. This involves showing empathy, understanding, and support without criticizing or condemning the client. By adopting a nonjudgmental attitude, the nurse can create a safe environment for open communication and collaboration to explore the reasons behind the client's non-adherence. This approach helps build trust and rapport, which are essential for promoting positive behavior change and improving treatment adherence. In contrast, being indifferent, demanding, or confrontational can lead to defensiveness, resistance, and further non-adherence in the client.