A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.