The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?

Correct Answer: D

Rationale: Advanced age is a nonmodifiable risk factor for diabetes mellitus. Nonmodifiable risk factors are characteristics or traits that cannot be changed or controlled. In this case, a person's age is a factor that continuously increases as time passes and cannot be altered. Other nonmodifiable risk factors for diabetes mellitus include family history of diabetes and certain ethnic backgrounds. On the other hand, poor control of blood glucose levels, current or recent foot trauma, and inappropriate foot care are examples of modifiable risk factors that can be managed through lifestyle changes and proper medical care.

Correct Answer: D

Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.

Correct Answer: D

Rationale: In the acute stage of an unconscious patient like Mr. Franco, the most critical assessment is ensuring the patency of the airway and evaluating the adequacy of respiration. Maintaining a clear airway is essential to ensure that oxygen can reach the lungs and be circulated to vital organs. Without proper airway management, a patient's condition can quickly deteriorate due to hypoxia, leading to severe complications or even death. Therefore, assessing and securing the airway is the priority in the initial management of an unconscious patient to maintain adequate oxygenation and ventilation. Monitoring the respiration rate, depth, and effort is crucial to identify any signs of respiratory distress or failure that require immediate intervention. Once the airway and breathing are addressed, further assessments related to neurological function and sensory responses can be conducted.

Correct Answer: D

Rationale: Tinnitus (ringing in the ears) is a potential side effect of aspirin overdose. Aspirin can cause toxicity with symptoms like ringing in the ears, dizziness, confusion, and nausea. It is important for the adult to seek medical attention if they are experiencing tinnitus while on long-term aspirin therapy to address the possible overdose situation.

Correct Answer: D

Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.