The nurse is performing discharge planning for a client newly diagnosed with type 1 diabetes mellitus. It would be most important for the plan to include:
using a 23 gauge 1/2 inch needle for subcutaneous insulin.
monitoring the skin for dryness at injection site.
reporting multiple consecutive blood glucose levels over 200 mg/dL.
emphasizing the need to get eyes checked every 3 months.
The Correct Answer is C
A. While using the correct needle size is important for insulin administration, it is not the most critical aspect of discharge planning. The focus should be on managing blood glucose levels and recognizing when medical intervention is needed.
B. Monitoring the skin for dryness at the injection site is a good practice, but it is not the most urgent issue to address in discharge planning for a newly diagnosed diabetic client.
C. Consistently elevated blood glucose levels above 200 mg/dL may indicate poor control of diabetes and require prompt adjustments in treatment. Teaching the client to recognize and report hyperglycemia is essential to prevent complications such as diabetic ketoacidosis (DKA).
D. Eye exams are important for long-term diabetes management to monitor for diabetic retinopathy, but every 3 months is excessive. Annual eye exams are typically sufficient unless otherwise indicated by the healthcare provider.
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Correct Answer is C
Explanation
A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.
Correct Answer is B
Explanation
A. Stomatitis is a common side effect of radiation therapy for oral cancer, and while it requires management, it is not immediately life-threatening.
B. Stridor indicates potential airway obstruction, which is a critical and urgent condition that requires immediate intervention, making it the greatest concern among the options presented.
C. Nausea is a typical side effect of cancer treatment but is usually manageable and not considered an immediate threat.
D. Xerostomia, or dry mouth, is another common side effect of radiation to the head and neck, but it is not as urgent as the risk of airway compromise indicated by stridor.