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NurseDive Free Nursing Practice Question
A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?
A. "The insulin can be injected anywhere there is adipose tissue."
This statement does not indicate a need for further teaching, as it is correct that insulin can be injected anywhere there is adipose tissue. Adipose tissue is the layer of fat under the skin that can absorb insulin and prevent damage to muscles or organs. The common sites for insulin injection are the abdomen, thighs, buttocks, or upper arms.
B. "I will be sure my child rotates sites after 5 injections in one area."
This statement does not indicate a need for further teaching, as it is correct that the child should rotate sites after 5 injections in one area. Rotating sites can prevent lipodystrophy, which is a condition that causes abnormal changes in fat tissue due to repeated injections. Lipodystrophy can affect the appearance and absorption of insulin in the affected area.
C. "I will be sure my child aspirates before injecting the insulin."
This statement indicates a need for further teaching, as it is incorrect that the child should aspirate before injecting the insulin. Aspiration is the process of pulling back on the plunger of the syringe to check for blood before injecting the medication. Aspiration is not recommended for insulin injection, as it can cause pain, bruising, or leakage of insulin from the injection site.
D. "The insulin should be injected at a 90-degree angle."
This statement does not indicate a need for further teaching, as it is correct that insulin should be injected at a 90-degree angle. Injecting insulin at a 90-degree angle can ensure that the medication reaches the adipose tissue and prevents skin irritation or muscle damage. The only exception is if the child has very thin skin or uses very short needles, in which case they may inject at a 45-degree angle.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Pediatric Proctored Exam 3. Take the full exam now
Full Explanation
Choice A: This statement does not indicate a need for further teaching, as it is correct that insulin can be injected anywhere there is adipose tissue. Adipose tissue is the layer of fat under the skin that can absorb insulin and prevent damage to muscles or organs. The common sites for insulin injection are the abdomen, thighs, buttocks, or upper arms.
Choice B: This statement does not indicate a need for further teaching, as it is correct that the child should rotate sites after 5 injections in one area. Rotating sites can prevent lipodystrophy, which is a condition that causes abnormal changes in fat tissue due to repeated injections. Lipodystrophy can affect the appearance and absorption of insulin in the affected area.
Choice C: This statement indicates a need for further teaching, as it is incorrect that the child should aspirate before injecting the insulin. Aspiration is the process of pulling back on the plunger of the syringe to check for blood before injecting the medication. Aspiration is not recommended for insulin injection, as it can cause pain, bruising, or leakage of insulin from the injection site.
Choice D: This statement does not indicate a need for further teaching, as it is correct that insulin should be injected at a 90-degree angle. Injecting insulin at a 90-degree angle can ensure that the medication reaches the adipose tissue and prevents skin irritation or muscle damage. The only exception is if the child has very thin skin or uses very short needles, in which case they may inject at a 45-degree angle.
Similar Questions
A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect?
A. Muscular dystrophy
Muscular dystrophy is not an example of a neural tube defect, but rather a group of genetic disorders that cause progressive weakness and loss of muscle mass. Muscular dystrophy affects the skeletal muscles that control movement and may also affect the heart, lungs, or other organs. Muscular dystrophy is caused by mutations in genes that encode proteins that protect muscle fibers from damage.
B. Spina bifida
Spina bifida is an example of a neural tube defect, which is a birth defect that occurs when the neural tube, which is the structure that develops into the brain and spinal cord, does not close completely during the first month of pregnancy. Spina bifida causes an opening in the spine that exposes the spinal cord and nerves and may result in physical and mental disabilities. Spina bifida can be prevented by taking folic acid before and during pregnancy.
C. Hydrocephalus
Hydrocephalus is not an example of a neural tube defect, but rather a condition that causes accumulation of cerebrospinal fluid (CSF) in the brain. Hydrocephalus can increase the pressure inside the skull and damage the brain tissue and function. Hydrocephalus can be caused by congenital defects, infections, injuries, tumors, or bleeding in the brain.
D. Cerebral palsy
Cerebral palsy is not an example of a neural tube defect, but rather a group of disorders that affect movement, balance, and posture. Cerebral palsy is caused by damage to the developing brain before, during, or after birth. Cerebral palsy can affect muscle tone, coordination, reflexes, or speech. Cerebral palsy can be caused by infections, injuries, lack of oxygen, or genetic mutations.
Full Explanation
Choice A: Muscular dystrophy is not an example of a neural tube defect, but rather a group of genetic disorders that cause progressive weakness and loss of muscle mass. Muscular dystrophy affects the skeletal muscles that control movement and may also affect the heart, lungs, or other organs. Muscular dystrophy is caused by mutations in genes that encode proteins that protect muscle fibers from damage.
Choice B: Spina bifida is an example of a neural tube defect, which is a birth defect that occurs when the neural tube, which is the structure that develops into the brain and spinal cord, does not close completely during the first month of pregnancy. Spina bifida causes an opening in the spine that exposes the spinal cord and nerves and may result in physical and mental disabilities. Spina bifida can be prevented by taking folic acid before and during pregnancy.
Choice C: Hydrocephalus is not an example of a neural tube defect, but rather a condition that causes accumulation of cerebrospinal fluid (CSF) in the brain. Hydrocephalus can increase the pressure inside the skull and damage the brain tissue and function. Hydrocephalus can be caused by congenital defects, infections, injuries, tumors, or bleeding in the brain.
Choice D: Cerebral palsy is not an example of a neural tube defect, but rather a group of disorders that affect movement, balance, and posture. Cerebral palsy is caused by damage to the developing brain before, during, or after birth. Cerebral palsy can affect muscle tone, coordination, reflexes, or speech. Cerebral palsy can be caused by infections, injuries, lack of oxygen, or genetic mutations.
A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
A. Torticollis
Torticollis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes tilting or twisting of the neck due to contraction or spasm of the sternocleidomastoid muscle. Torticollis can cause pain, stiffness, or limited range of motion in the neck. Torticollis can be congenital or acquired due to injury, infection, or posture.
B. Lordosis
Lordosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive inward curvature of the lower spine. Lordosis can cause back pain, stiffness, or difficulty in movement. Lordosis can be congenital or acquired due to obesity, pregnancy, osteoporosis, or spondylolisthesis.
C. Kyphosis
Kyphosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive outward curvature of the upper spine. Kyphosis can cause a hunchback appearance, back pain, stiffness, or breathing problems. Kyphosis can be congenital or acquired due to aging, osteoporosis, arthritis, or spinal injury.
D. Scoliosis
Scoliosis is a disorder that causes lateral curvature of the spine in one or more places. Scoliosis can cause uneven shoulders or hips, back pain, fatigue, or breathing problems. Scoliosis can be congenital or idiopathic (unknown cause). Scoliosis can be diagnosed by physical examination and X-ray and treated by braces or surgery depending on the severity and progression of the curve.
Full Explanation
Choice A: Torticollis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes tilting or twisting of the neck due to contraction or spasm of the sternocleidomastoid muscle. Torticollis can cause pain, stiffness, or limited range of motion in the neck. Torticollis can be congenital or acquired due to injury, infection, or posture.
Choice B: Lordosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive inward curvature of the lower spine. Lordosis can cause back pain, stiffness, or difficulty in movement. Lordosis can be congenital or acquired due to obesity, pregnancy, osteoporosis, or spondylolisthesis.
Choice C: Kyphosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive outward curvature of the upper spine. Kyphosis can cause a hunchback appearance, back pain, stiffness, or breathing problems. Kyphosis can be congenital or acquired due to aging, osteoporosis, arthritis, or spinal injury.
Choice D: Scoliosis is a disorder that causes lateral curvature of the spine in one or more places. Scoliosis can cause uneven shoulders or hips, back pain, fatigue, or breathing problems. Scoliosis can be congenital or idiopathic (unknown cause). Scoliosis can be diagnosed by physical examination and X-ray and treated by braces or surgery depending on the severity and progression of the curve.
A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
A. Reposition the client by log rolling every 2 hours.
In actual practice, log rolling is typically done every 2 hours to align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT). as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff members to assist with log rolling.
B. Keep the head of the bed at a 30-degree angle.
This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.
C. Place the client in protective isolation.
This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. The nurse should follow standard precautions and surgical site care to prevent infection in this client.
D. Initiate the use of a PCA pump for pain control.
This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.
Full Explanation
Choice A: In actual practice, log rolling is typically done every 2 hours to align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT).
as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff
members to assist with log rolling.
Choice B: This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.
Choice C: This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. The nurse should follow standard precautions and surgical site care to prevent infection in this client.
Choice D: This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.