The Client with Insulin-Dependent Diabetes Mellitus

17.

A student with type 1 diabetes tells the nurse she is feeling light-headed. The student’s blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:

■ 1. Give 15 mL of juice and give another 15 mL in 15 minutes.

■ 2. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.

■ 3. Give 15 g of carbohydrate and 15 g of protein.

■ 4. Give 15 oz of juice and retest in 15 minutes

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21.

An 8-year-old with newly diagnosed dia- betes is in the hospital for regulation of diet and medications. The child is using an exchange method for the diet. The nurse should instruct the client that the American Diabetes Association’s (ADA’s) exchange method for dietary regulation includes:

■ 1. Choosing food from each exchange list.

■ 2. Using a scale to weigh all food.

■ 3. Selecting from lists that group food accord- ing to protein, fat, and carbohydrate content.

■ 4. Carbohydrate counting for each meal and snack.

22.

A 14-year-old is using glargine (Lantus) and lispro (Humolog) to manage type I diabetes. The order for sliding scale lispro reads:

Lispro subcutaneous give units according to sliding scale:

Blood glucose: 70 – 150 mg/dL = 0 units 151–200 mg/dL = 1 unit

201–250 mg/dL = 2 units 251–300 mg/dL = 3 units 301–350 mg/dL = -4 units Call for Blood glucose > 350 In addition give 1 unit for every

15 grams of carbohydrate.

The morning blood glucose is 202 mg/dL and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro?

______________________units.

23.

An 8-year-old with diabetes is placed on neutral protamine Hagedorn (NPH) and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. The snack will:

■ 1. Help her regain lost weight.

■ 2. Provide carbohydrates for immediate use.

■ 3. Prevent late night hypoglycemia.

■ 4. Help her stay on her diet.

24.

A nurse is teaching an 8-year-old with diabe- tes and her parents about managing diabetes during illness. The nurse determines the parents under- stand the instruction when they indicate that, when the child is ill, they will provide:

■ 1. More calories.

■ 2. More insulin.

■ 3. Less insulin.

■ 4. Less protein and fat.

18.

An overweight adolescent has been diag- nosed with type 2 diabetes. To increase the client’s self-effi cacy to manage their disease, the nurse should:

■ 1. Provide the client with a written daily food and exercise plan.

■ 2. Discuss eliminating junk food in the home with the parents.

■ 3. Arrange for the school nurse to weigh the child weekly.

■ 4. Utilize a peer with type 2 diabetes to role model lifestyle changes.

19.

After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin met- formin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and:■ 1. Replaces natural insulin.

■ 2. Helps the body make more insulin.

■ 3. Increases insulin sensitivity.

■ 4. Decreases carbohydrate adsorption.

20.

The nurse is evaluating a child’s skills in self-administering insulin (see fi gure). The nurse should:

■ 1. Have the child use both hands on the syringe.

■ 2. Ask the child to place the needle at a 45 degree angle.

■ 3. Tell the child to use a site lower on her thigh.

■ 4. Remind the child to rotate sites.

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Managing Care Quality and Safety

29.

The parent of a 17-year-old boy, who is hos- pitalized for complications related to type I diabetes, requests to review the adolescent’s medical record.

The client reported receiving mental health counsel- ing during the admission history, but did not want his parent to know. The nurse, who is uncertain of how to protect the adolescent’s privacy and accom- modate the parent’s request, should consult:

■ 1. The unit nurse manager.

■ 2. The primary care provider.

■ 3. The organization’s privacy offi cer.

■ 4. The customer service representative.

30.

The charge nurse on the pediatric fl oor has assigned a 6-year-old girl of Arab-American ethnic- ity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old’s mother is upset because the parent staying with the other child is the father. The nurse should:

■ 1. Explain to the parents that this room arrange- ment facilitates teaching.

■ 2. Reassign the children to different rooms.

■ 3. Offer the Arab-American parent another place to sleep.

■ 4. Refer the parent to the customer service rep- resentative.

31.

A 10-year old child is admitted to the hospi- tal with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply.

■ 1. Place the child on contact isolation.

■ 2. Wear a gown, mask, and gloves before enter- ing the room.

■ 3. Place the child in a room with a 10-year-old who has had chickenpox.

■ 4. Place the child in a negative air-fl ow room.

■ 5. Maintain isolation until lesions have disappeared.

32.

The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter’s condition. The nurse should reply:

■ 1. “I think that would be a good idea.”

■ 2. “What is it that concerns you about having the school know about your daughter’s condition?”

■ 3. “It would be fi ne not to tell your daughter’s friends, but the teacher must know.”

■ 4. “In order to keep your daughter safe, it is nec- essary for all adults in the school to know her condition.”

25.

A nurse is assessing an 8-year-old with diabe- tes who is experiencing hyperglycemia. Which symp- tom (s) indicate (s) that the hyperglycemia requires immediate intervention? Select all that apply.

■ 1. Weakness.

■ 2. Thirst.

■ 3. Shakiness.

■ 4. Hunger.

■ 5. Headache.

■ 6. Irritability.

■ 7. Dizziness.

26.

The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion?

■ 1. She asks the nurse for material on diabetes for a school paper.

■ 2. She introduces the nurse to her friends as “the one who taught me all about my diabetes.”

■ 3. She says, “I’ll try to tell my friends, but they’ll probably quit hanging out with me.”

■ 4. She asks her friends what they think about someone who has a lifelong illness.

27.

When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include?

■ 1. Adhere to the same schedule and type and amount of insulin.

■ 2. Immediately call the physician for informa- tion about what to do.

■ 3. Adjust insulin based on more frequent testing of blood glucose levels.

■ 4. Take the child to the emergency department for immediate care.

28.

An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifi es which of the following as a result of using the same site?

■ 1. Destruction of the fat tissue and poor absorp- tion.

■ 2. Destruction of nerves and painful neuritis.

■ 3. Destruction of the tissue and too-rapid insulin uptake.

■ 4. Development of resistance to insulin and need for increased amounts.

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to develop trust and thus attain optimal develop- ment. The parents of a child with a chronic problem may need more guidance to meet the child’s needs because of the focus on medical problems. The child’s lesions are secondarily infected and there- fore should not be contagious. Siblings do not need to stay away. Even with lesions that are infected, the child can still attend day care, but the child needs attention from the parents as well. Playing video games for several hours is not appropriate for a 9-month-old infant.

CN: Health promotion and maintenance;

CL: Synthesize

4.

3. Atopic dermatitis is a chronic pruritic dermatitis that usually begins in infancy. Many of the children diagnosed with it have a family history of eczema, allergies, or asthma. Atopic dermatitis is best treated with hydrating the skin, controlling the pruritus, and preventing secondary infection. Pat- ting the skin dry removes less natural skin moistur- izer and thus maintains skin hydration. Water has a drying effect on the skin. Playing in the tub for 30 minutes each night would deplete the skin of its natural moisturizers, thereby leading to increased pruritus and dry skin. Bubble baths are to be avoided in children with atopic dermatitis because they may act as an irritant, possibly exacerbating the condition. Also, bubble baths deplete the skin of its natural moisturizers. The issue is not whether the child bathes every night. Rather, the goal is to decrease dryness and itching.

CN: Physiological adaptation;

CL: Evaluate

5.

3. Impetigo involving several superfi cial lesions is usually treated topically, including wash- ing the affected areas, removing crusts, and applying antibiotic ointment several times a day. The child can return to day care or school after being treated for 24 hours. The lesions do not need to be covered, they can remain open to the air. There is no need for follow-up unless the lesions have not resolved or have become more severe.

CN: Physiological adaptation;

CL: Create

6.

4. Scabies is caused by the scabies mite, Sarcoptes scabiei. The mite burrows into the stra- tum corneum of the epidermis, where the female deposits eggs and fecal material. These burrows are linear. Scabies is highly contagious. The length of time from infestation to physical symptoms is 30 to 60 days, so everyone in close contact with the child will need to be treated. The bed linens and the child’s clothing should be washed in hot water and dried on the hot setting. It is not neces- sary to damp mop the fl oors to prevent the spread of scabies. The child should be held minimally

Answers, Rationales, and Test Taking Strategies

The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.

For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.

The Client with Skin Disorders

1.

1. Because of the risk of birth defects with isotretinoin, the FDA has created a web-based risk management plan known as iPLEDGE. The program requires that all clients meet qualifi cation criteria and monthly program requirements to obtain the medication. Currently, only providers enrolled in the iPLEDGE program can prescribe this medication and only clients who enroll in iPLEDGE can receive the drug. Providers are advised to closely monitor clients for signs of depression, but a mental health evaluation is not universally required. Women of child bearing age must use two forms of effective birth control for two months before, during, and 1 month after taking the drug. Isotretinoin may cause muscle aches and extreme exercise should be avoided, but general participation in sports should be considered on an individual basis.

CN: Safety and infection control;

CL: Synthesize

2.

1. Washing the face once or twice a day with a mild soap removes fatty acids from the skin. Acne is an infl ammation of the sebaceous glands that pro- duce sebum. Washing the face with mild soap and water keeps the sebaceous glands from becoming plugged. Excessive washing or squeezing the erup- tions can cause rupture of these glands, spreading the sebum and causing further infl ammation.

Applying vitamin E to the lesions does not reduce the infl ammation and, due to the greasiness of the preparation, may plug the ducts. Retin-A should be applied at night. Exposure to the sun can result in sunburn and an increased risk of skin cancer and should be avoided. Sunscreen with a sun protection factor of at least 15 must be applied before the client can be exposed to the sun.

CN: Physiological adaptation;

CL: Synthesize

3.

4. The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents

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doing so is inappropriate because the dressing changes need to be performed as ordered to ensure effectiveness and healing.

CN: Physiological adaptation;

CL: Synthesize

11.

2. Withholding certain foods until the child complies is punitive and rarely successful. Allow- ing the mother to feed the child, serving smaller and more frequent meals, and offering fi nger foods are all acceptable interventions for a 5-year-old child.

This is true whether the child is well or ill.

CN: Basic care and comfort;

CL: Evaluate

12.

1. Hypoproteinemia is common after severe burns. The child’s diet should be high in protein to compensate for protein loss and to promote tis- sue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and cel- ery sticks is lacking in suffi cient protein and calo- ries.

CN: Physiological adaptation;

CL: Evaluate

13.

3. A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with hips and knees fl exed often encourages contracture formation.

CN: Reduction of risk potential;

CL: Synthesize

The Client with Hyperthyroidism

14.

3. Most clients will need lifelong thyroid replacement after treatments with radioactive iodine. Most clients are treated as outpatients.

To reduce the risk of exposure to radioactivity to others, clients are advised to avoid public places for at least 1 day and maintain a prudent distance from others for 2 to 3 days. Additionally, clients are advised to avoid close contact with pregnant women and children for 5 to 11 days. The use of radioiodine to treat Graves’ disease has not been found to affect long-term fertility. Clients are taught not to share food, utensils, and towels. Use of a private bathroom is desirable. Clients are also instructed to fl ush the toilet more than one time after each use.

CN: Safety and infection control;

CL: Evaluate until treatment is completed. Family members

should wash their hands after contact with the child. Itching lasts for 2 to 3 weeks until the stra- tum corneum is replaced.

CN: Safety and infection control;

CL: Create

The Client with Burns

7.

3. To prevent further injury to the skin, the mother should apply cool water to the burn site.

Doing so causes vasoconstriction, retards further damage to tissues, and decreases fl uid loss. Keep- ing the child warm promotes vasodilation, increases fl uid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immedi- ately.

CN: Health promotion and maintenance;

CL: Synthesize

8.

2. The child has burns of the entire leg.

Because of the smaller size of children’s legs, the estimate of 14% is used instead of 18%, which is used with adults. The arms of children are estimated at 9%, and the anterior and posterior trunk at 18%

each. The head of the child is estimated at 18%, rather than the 9% used for adults.

CN: Physiological adaptation;

CL: Analyze

9.

250 mL/hour

2,000 mL ÷ 8 hours = 250 mL/hour CN: Pharmacological and parenteral therapies; CL: Apply

10.

2. Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feel- ings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation,

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and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.

CN: Management of care; CL: Synthesize

19.

3. Metformin is currently approved by the FDA to treat type 2 diabetes in children. The medication decreases glucogenesis in the liver and increases insulin sensitivity in the peripheral tissues. Only insulin can actually replace insulin.

This treatment is reserved for clients with type 1 diabetes or those with type 2 who do not respond to diet, exercise, and an oral diabetic agent. Other oral medications used to treat diabetes augments insulin production or decreases carbohydrate absorption, but those medications are primarily used in adults.

CN: Pharmacological and parenteral therapies; CL: Apply

20.

4. The child is using correct injection tech- nique, and the nurse can remind the child to rotate sites. The nurse should also reinforce that the child has used correct technique and praise the child for doing so. If the child can manipulate the plunger of the syringe with one hand, this is appropriate.

Insulin is administered at a 90 degree angle as shown. The child should identify appropriate sites on the thighs as one handbreadth below the hip and above the knee; the child is using appropriate sites.

CN: Health promotion and maintenance;

CL: Apply

21.

4. Carbohydrate counting identifi es the number of grams of carbohydrate to be eaten at each meal and snack. The ADA’s exchange diet allows the substitution of one food for another on the same diet list. The exchange list does not require that all food is weighed. Choices are made from lists referred to as carbohydrate, meat or meat substitute, and fat.

The client’s prescription identifi es how many items from each food group are to be consumed at each meal and snack. The exchange assumes that foods with similar nutrient content affect blood glucose levels in a similar manner.

CN: Physiological adaptation;

CL: Apply

22.

4 units. Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake.

CN: Pharmacological and parenteral therapies; CL: Apply

23.

3. NPH insulin peaks in 6 to 8 hours, which would occur during sleep. A bedtime snack is needed to prevent late night hypoglycemia. The

15.

3. Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child’s condi- tion improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is com- mon and bathing should be encouraged.

CN: Physiological adaptation;

CL: Synthesize

16.

4. Because it takes approximately 2 weeks before the response to drug treatment occurs, much of the child’s care focuses on managing the child’s physical symptoms. Signs and symptoms of the disorder include inability to sit still or concentrate, increased appetite with weight loss, emotional lability, and fatigue. Nursing care is directed toward ensuring that the mother and teacher know how to handle the child, suggesting a shortened school day, a nonstimulating environment, and decreased stress and workload. The child should be encouraged to eat a well-balanced diet.

CN: Physiological adaptation; CL: Create

The Client with Insulin-Dependent Diabetes Mellitus

17.

2. The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 calories and is roughly equal to ½ cup of juice or soda, 6 to 8 lifesavers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 15 calories. This would not be suf- fi cient carbohydrates to treat the hypoglycemia.

Protein does not treat insulin-related hypoglyce- mia; however a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be almost 4 times the recommended 4 oz of juice.

CN: Physiological adaptation;

CL: Synthesize

18.

4. Self-effi cacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models.

Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors.

Providing a written plan alone does not promote self-effi cacy. Having parents eliminate junk food

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