A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply)

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

Choice A reason: Attaching restraints to movable side rails is unsafe, as rail movement can cause injury or loosen restraints. They should be secured to the bed frame, a fixed structure, so this guideline is incorrect and dangerous for restraint protocols.
Choice B reason: Documenting the client’s condition every 15 minutes ensures frequent monitoring for safety, circulation, and skin integrity, per CMS and Joint Commission standards. This prevents complications and supports timely restraint removal, making it the correct guideline.
Choice C reason: Requesting PRN restraint prescriptions is inappropriate, as restraints require specific, time-limited orders based on immediate need. PRN orders lack oversight and risk misuse, so this guideline is incorrect and non-compliant with regulations.
Choice D reason: Applying restraints over clothing can cause discomfort or skin irritation, as direct skin contact with padding is preferred for safety. This guideline is incorrect, as proper application minimizes harm, making it inappropriate for protocols.