A nurse in an outpatient mental health clinic is assessing an adolescent client.
The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

The correct answer is choice C: Initiate continuous cardiac monitoring.

Choice A rationale:

Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.

Choice B rationale:

Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.

Choice C rationale:

Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.

Choice D rationale:

Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.

Choice A rationale:

Clients with dementia often experience difficulties with memory, cognition, and orientation, which can lead to increased risk of falls and injuries, especially when trying to perform activities of daily living such as using the toilet. Assisting the client to the toilet frequently helps prevent accidents and reduces the risk of injury from falls. Timely toileting can also improve the client's comfort and overall quality of life.

Choice B rationale:

Raising the side rails up when the client is in bed can create a physical barrier, but it is not a recommended method to prevent falls in clients with dementia. In fact, it can pose a risk by confining the client and may lead to attempts to climb over the rails, resulting in falls and injuries.

Choice C rationale:

Placing the bedside table at the foot of the bed does not directly address the client's safety needs. While it might be a matter of personal preference or convenience, it does not significantly impact the client's risk of injury.

Choice D rationale:

Keeping the television on during the night does not address the client's physical safety. While it may provide entertainment or a familiar environment, it does not mitigate the risk of falls or injuries, which is the primary concern when caring for clients with dementia.