Nur 255 B Adult Health 1 CBU

Correct Answer: "Your request to not receive a transfusion will be honored. Your consent is needed to administer blood or blood products."

This response respects the client's autonomy and their religious beliefs. Jehovah's Witnesses typically refuse blood transfusions based on their religious convictions, so the nurse must respect that decision and confirm that the patient’s wishes will be honored.

Additionally, it provides important information about the need for consent to administer blood products, ensuring the client understands their rights.

Why the other options are less appropriate:

"Tell me about your fear of receiving a blood transfusion.": While it's important to address any fears, the concern here is more about the religious belief against blood transfusions rather than fear. This response does not directly affirm the patient’s wishes and may lead to unnecessary discussion about something that is already clear."

"You don't need to worry about getting a blood transfusion. We have newer equipment that causes less blood loss during surgery.": This response dismisses the patient’s religious beliefs and assumes that the patient might accept a transfusion. It doesn’t acknowledge the seriousness of the patient’s request or their right to refuse blood products.

"Are you sure you wouldn't want a blood transfusion if one is needed during surgery? You can always change your mind after surgery.": This response undermines the patient’s decision and creates doubt about their wishes. It implies that the patient may be coerced into changing their mind, which is not respectful of the patient's rights.

Key Point:

When a patient refuses medical treatment based on religious or personal beliefs, it is essential to respect their wishes and ensure that their rights are upheld throughout the care process.

Correct Answer: Shakiness

Hypoglycemia (low blood sugar) and diabetic ketoacidosis (DKA) are two distinct complications of diabetes, and it’s crucial for patients to recognize the symptoms of each in order to manage them properly. 

Shakiness is a common symptom of hypoglycemia, and it occurs when blood sugar levels drop too low. To correct this, the patient should consume glucose or a fast-acting carbohydrate, such as fruit juice or a glucose tablet. If a patient experiences shakiness, they should take glucose or food to raise their blood sugar.

Why the other options are incorrect:

Fruity breath odor:

Fruity breath odor is a classic sign of diabetic ketoacidosis (DKA), not hypoglycemia. It occurs due to the production of acetone (a type of ketone) when the body breaks down fat for fuel instead of glucose. If a patient experiences fruity breath, it indicates that they may need to seek medical treatment for DKA, not take glucose.

Polyuria:

Polyuria (increased urination) is also more commonly associated with diabetic ketoacidosis (DKA) or hyperglycemia (high blood sugar), as the kidneys attempt to rid the body of excess glucose. This symptom is not an indicator to take glucose or food, as it suggests elevated blood sugar rather than low blood sugar.

Blurred vision:

Blurred vision can occur in both hypoglycemia and hyperglycemia. However, it is a less specific symptom that does not directly indicate the need for immediate glucose or food. If blurred vision occurs with shakiness or other hypoglycemia signs, it’s more likely related to low blood sugar, but blurred vision alone is not enough to determine the cause.

Summary:

Shakiness is the symptom most closely associated with hypoglycemia, and glucose or food should be consumed when this symptom arises.

Correct Answer "I will consume no more than 8 oz. of alcohol per week."

Glyburide is a sulfonylurea, a class of medications used to lower blood glucose levels by stimulating the beta cells of the pancreas to produce more insulin. However, alcohol consumption can interact with sulfonylureas in a way that increases the risk of hypoglycemia (low blood sugar).

Alcohol can interfere with the liver's ability to release glucose, potentially leading to dangerously low blood sugar levels, especially when combined with medications like Glyburide.

The concern with the statement "I will consume no more than 8 oz. of alcohol per week" is that it suggests the patient may underestimate the potential danger of alcohol intake while taking Glyburide, as even small amounts of alcohol can increase the risk of hypoglycemia. Patients on sulfonylureas are generally advised to avoid alcohol or consume it with caution and under the guidance of their healthcare provider.

Why the other statements are appropriate:

"I will monitor my blood glucose regularly because I know this medication can cause a low blood sugar.": This statement is correct and shows the patient understands that hypoglycemia is a risk of Glyburide, and regular blood glucose monitoring is an important safety measure.

"I will continue monitoring my diet and participating in exercise while taking this medication.": This statement is also appropriate, as diet and exercise are important components of managing Type 2 diabetes, and Glyburide works best when combined with a healthy lifestyle.

"This medication works by stimulating the beta cells in the pancreas to make insulin.": This statement is correct. Glyburide works by stimulating the pancreas to release more insulin, helping lower blood glucose levels.

Correct Answer: The recent move to an assisted living facility

Grief can arise from significant life changes, and a recent move to an assisted living facility is a major life event that can trigger feelings of grief, loss, and adjustment.

The transition often involves leaving behind a familiar environment, social network, and independence, which can lead to emotional distress, sadness, and grief.

Why the Other Options Are Incorrect:

Being diagnosed with Type 1 diabetes mellitus as a child:

While chronic illness and its management can lead to emotional stress, the diagnosis itself, especially in childhood, is less likely to cause grief symptoms in older adulthood compared to more recent significant losses.

The loss of a pregnancy 20 years ago:

Though the loss of a pregnancy can cause grief at the time, it is less likely to be the cause of new grief symptoms after a long time has passed unless it was unresolved, which isn't typically the case after two decades.

The loss of a spouse 5 years ago:

While the loss of a spouse can lead to prolonged grief, it occurred five years ago, and typically, significant grief from the loss of a spouse would have been experienced in the first few months or years following the death. If the client has had time to process this loss, it is less likely to be the immediate cause of new grief symptoms.

Summary:

The most likely cause of the client's new grief symptoms is the recent move to an assisted living facility. This life transition can be a significant source of emotional distress, and the client may be grieving the loss of independence, familiar surroundings, and previous social connections.

Correct Answer: Respiratory acidosis

To interpret the blood gas values and determine the condition, let’s break down the components of the arterial blood gases (ABG):

PCO2 (partial pressure of carbon dioxide): 59 mmHg

Normal range: 35-45 mmHg

The high PCO2 indicates retention of CO2, which is a characteristic of respiratory acidosis. CO2 is acidic, so when it accumulates in the body, it causes the blood pH to drop (become more acidic).

pH: 7.26

Normal range: 7.35-7.45

The pH of 7.26 is low, indicating acidosis.

HCO3 (bicarbonate): 42 mEq/L

Normal range: 22-28 mEq/L

A high HCO3 level suggests that the body is attempting to compensate for the respiratory acidosis. The kidneys try to neutralize the acid by retaining bicarbonate in response to the elevated CO2 levels.

Analysis of the Blood Gas:

The high PCO2 and low pH suggest respiratory acidosis because the problem originates in the lungs, where CO2 is not being expelled effectively (common in conditions like COPD).

The elevated HCO3 indicates that the kidneys are compensating for the respiratory acidosis by retaining bicarbonate to help buffer the excess acid.

Why the other options are incorrect:

Respiratory alkalosis:

This would be indicated by a low PCO2 (due to hyperventilation) and a high pH, but in this case, the PCO2 is elevated, and the pH is low, which supports acidosis, not alkalosis.

Metabolic alkalosis:

This would be indicated by a high pH and high HCO3 levels, but the pH is low in this case, which eliminates metabolic alkalosis.

Metabolic acidosis:

This would be indicated by a low pH and low HCO3 levels, but the HCO3 is high, indicating that the body is compensating for the acidosis, which makes metabolic acidosis unlikely.

Summary:

The blood gas values of PCO2 59, pH 7.26, and HCO3 42 are indicative of respiratory acidosis with renal compensation (elevated bicarbonate). This is common in patients with chronic obstructive pulmonary disease (COPD), where CO2 retention occurs due to impaired gas exchange in the lungs.

Correct Answer:"I will eat more fruits and vegetables, especially green leafy ones, to get more B12 in my diet."

This statement indicates a need for additional teaching because green leafy vegetables are a source of folic acid, not vitamin B12. Vitamin B12 is primarily found in animal-based products such as meat, fish, eggs, and dairy.

While eating fruits and vegetables is important for a balanced diet, they do not provide sufficient vitamin B12, which is essential for addressing anemia related to B12 deficiency.

Why the Other Statements Are Correct:

"I will take vitamins with extra iron in addition to eating a balanced diet with meat to correct my anemia."

This is correct because iron supplementation is often necessary for correcting iron deficiency anemia, and a balanced diet that includes meat (a rich source of heme iron) is beneficial.

"I will add food high in vitamin C to improve my absorption of iron in both my vitamins."

This is correct because vitamin C enhances the absorption of non-heme iron from plant-based foods and supplements.

"I will need to include more protein foods in my diet such as meats, dried beans, and whole-grain bread."

This is correct because protein-rich foods such as meat are excellent sources of heme iron, and beans and whole-grain bread are good sources of non-heme iron.

Additional Teaching Point:

For someone with iron deficiency anemia, the focus should be on increasing iron intake through heme iron sources (meat, poultry, fish) and enhancing absorption of non-heme iron (found in plant-based sources like spinach and beans) with vitamin C.

Vitamin B12 is important for certain types of anemia, but it is not a focus of treatment for iron deficiency anemia unless there is a coexisting B12 deficiency.

Correct Answer: Leg edema, severe pain from swelling and erythema

Local inflammation typically involves the body's response to injury, infection, or irritation, resulting in the classic signs of redness (erythema), heat, swelling (edema), and pain.

The symptoms in option B, including leg edema, severe pain, and erythema, are indicative of local inflammation.

Leg edema: Swelling occurs due to fluid accumulation from increased vascular permeability during inflammation.

Severe pain: Pain is a hallmark of inflammation, often due to pressure from the swelling or the release of inflammatory mediators.

Erythema (redness): Increased blood flow to the affected area causes redness, which is a common sign of local inflammation.

Why the Other Options Are Incorrect:

Leg edema, tachycardia, leg cool to touch:

While leg edema is present, tachycardia and coolness to touch suggest systemic involvement (such as shock or a circulatory problem) rather than local inflammation. Inflammation would more likely cause warmth, not coolness.

Increased HR, hypotension, cold-moist skin:

These signs are more indicative of systemic issues, such as sepsis or shock, rather than localized inflammation. Local inflammation doesn't typically cause systemic symptoms like increased heart rate, hypotension, or cold skin.

T 101.8, diaphoresis, HR 120:

These symptoms suggest fever and systemic infection, not localized inflammation. The fever and elevated HR are more likely signs of systemic infection, such as sepsis, which involves the whole body, not just a localized area.

Summary:

Local inflammation is most accurately identified by signs like edema, pain, and erythema in the affected area, as described in option B.

Correct answer: Insert an NG and maintain NPO status to allow pancreas to rest.

In the management of acute pancreatitis, the main goal is to rest the pancreas and prevent further irritation or injury. The intervention that supports this goal is to maintain the patient NPO (nothing by mouth), which minimizes stimulation of the pancreas and allows it to heal.

In addition, nasogastric (NG) tube insertion may be necessary if the patient is experiencing severe vomiting or abdominal distension. The NG tube can help decompress the stomach and prevent aspiration while the pancreas is at rest.

Why the Other Options Are Incorrect:

Immediately start enteral feeding to prevent malnutrition:

Enteral feeding is typically not started immediately in acute pancreatitis. The initial treatment involves resting the pancreas, which means no oral intake for a period of time. Once the patient's symptoms improve (usually after a few days), enteral feeding may be considered to support nutrition, but it should not be started immediately.

Initiate early prophylactic antibiotic therapy to prevent infection:

Prophylactic antibiotics are not recommended for acute pancreatitis unless there is evidence of infection (e.g., infected pancreatic necrosis). Most cases of acute pancreatitis are not caused by infection, and the use of antibiotics is generally reserved for specific complications.

Administer acetaminophen (Tylenol) every 4 hours for pain relief:

Acetaminophen is not the ideal choice for pain relief in acute pancreatitis, as it may not be strong enough to manage the severe pain associated with the condition. The pain in pancreatitis is usually treated with opioid analgesics such as morphine or hydromorphone, as these are more effective in managing the intensity of pain in acute pancreatitis. Additionally, frequent use of acetaminophen can be risky for liver function, particularly in critically ill patients.

Summary:

In acute pancreatitis, the best initial intervention is to maintain NPO status and allow the pancreas to rest. Nasogastric (NG) tube insertion may be used to manage vomiting or gastric distention.

Other interventions, such as enteral feeding, antibiotics, and acetaminophen, are not appropriate in the acute phase and may not align with the goals of initial treatment.

Correct Answer:126

A fasting blood glucose level above 126 mg/dL on two separate occasions is a diagnostic criterion for diabetes.

Diagnostic Criteria for Diabetes:

Fasting blood glucose of 126 mg/dL or higher.

Random blood glucose of 200 mg/dL or higher with symptoms of hyperglycemia.

Oral glucose tolerance test (OGTT): A two-hour plasma glucose level of 200 mg/dL or higher.

A1C of 6.5% or higher.

Why the Other Options Are Incorrect:

110 mg/dL: A fasting glucose level of 110 mg/dL is considered impaired fasting glucose (pre-diabetes), not diabetes.

200 mg/dL: A fasting blood glucose of 200 mg/dL is too high to be considered normal, but 200 mg/dL is the threshold for diagnosing diabetes in a random glucose test.

156 mg/dL: A fasting blood glucose of 156 mg/dL would be above normal, but it does not meet the criteria for diabetes (126 mg/dL is the threshold).

Summary:

A fasting glucose level above 126 mg/dL is indicative of diabetes.