A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include?

Choice A: This instruction is incorrect, as withholding insulin dose if feeling nauseous can cause hyperglycemia, which is high blood sugar, and diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should take their insulin dose as prescribed and monitor their blood sugar levels more frequently when they are sick.

Choice B: This instruction is unnecessary, as notifying the provider if blood glucose levels are within normal parameters does not require any action or intervention. The child and the parents should notify the provider if blood glucose levels are above or below the target range, which is usually 70 to 180 mg/dL for children with type 1 diabetes mellitus. The child and the parents should also notify the provider if they have any signs or symptoms of hypoglycemia, hyperglycemia, or diabetic ketoacidosis.

Choice C: This instruction is incorrect, as limiting fluid intake during mealtime can cause dehydration, which can worsen the symptoms and complications of type 1 diabetes mellitus. Dehydration can cause increased thirst, dry mouth, fatigue, headache, or dizziness. The child should drink plenty of fluids during meal time and throughout the day to hydrate their body and flush out excess glucose and ketones.

Choice D: This instruction is correct, as testing the urine for ketones can help detect diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should test their urine for ketones when their blood sugar levels are above 240 mg/dL or when they are sick. The child and the parents should notify the provider if the urine test shows moderate or large amounts of ketones.

Choice A: Skin cancer is a malignant growth of the skin cells, which can be caused by exposure to ultraviolet radiation, genetic mutations, or immunosuppression. Skin cancer does not affect the mouth and does not cause a white, milky plaque. Skin cancer may cause changes in the color, shape, size, or texture of a mole or a skin lesion.

Choice B: Candidiasis or thrush is a fungal infection of the mouth, which can be caused by overgrowth of Candida albicans, a type of yeast that normally lives in the body. Candidiasis or thrush can occur in people who have a weakened immune system, such as those who have a systemic disorder, take antibiotics, immunosuppressants, or corticosteroids, or have a smoking history. Candidiasis or thrush can cause soreness in the mouth and difficulty eating. Candidiasis or thrush can also cause a white, milky plaque that does not come off with rubbing.

Choice C: Squamous cell carcinoma is a type of skin cancer that affects the squamous cells, which are flat cells that form the outer layer of the skin. Squamous cell carcinoma can occur in areas that are exposed to sun damage, such as the face, ears, lips, or neck. Squamous cell carcinoma does not affect the mouth and does not cause a white, milky plaque. Squamous cell carcinoma may cause a red, scaly, crusty, or bleeding bump or patch on the skin.

Choice D: Herpes simplex is a viral infection that affects the skin and mucous membranes, such as the mouth, lips, genitals, or eyes. Herpes simplex is transmitted by direct contact with an infected person or object. Herpes simplex does not cause a white, milky plaque. Herpes simplex may cause painful blisters or ulcers that burst and form scabs.