An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)

Measure pulse and blood pressure

Document anxiety on the surgical checklist

Assess skin temperature and moisture

Check fingerstick glucose level

Administer a PRN dose of regular insulin

Answer and Explanation

Correct Answer : A,C,D,E

A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.

B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.

C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.

D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.

E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.

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Correct Answer is A

Explanation

A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.

B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.

C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.

D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.

A. Remind the client to practice pelvic floor (Kegel) exercises regularly. B. Provide a bedside commode for immediate use in the client's room C. Explain the need to limit intake of oral fluids to reduce client discomfort. D. Teach the client techniques for performing intermittent catheterization.

Correct Answer is D

Explanation

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.

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An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Correct Answer is A

Explanation

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

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