A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

The correct answer is choiced. “I try not to look at the scales on my body.”

Choice A rationale:Limiting time spent in sunlight is generally a good practice for individuals with psoriasis, as excessive sun exposure can trigger flare-ups or worsen symptoms.

Choice B rationale:Removing old medication before applying a new dose is a proper practice to ensure the effectiveness of the treatment and prevent skin irritation.

Choice C rationale:Avoiding fabric softener is advisable for individuals with psoriasis, as fabric softeners can contain chemicals that may irritate sensitive skin.

Choice D rationale:This statement indicates a potential psychological impact of psoriasis on the client. It suggests that the client might be experiencing distress or avoidance behavior due to the appearance of their skin, which should be reported to the provider for further assessment and support.

Choice A rationale:

Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.

Choice B rationale:

Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.

Choice C rationale:

Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.

Choice D rationale:

Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.

Choice E rationale:

The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.

Choice F rationale:

Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.