Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"
Which are the nurse's best responses? Select all that apply.

A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.

B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.

C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.

D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.

E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.

A. Explain expected side effects of postoperative chemotherapy: Chemotherapy and its side effects are typically discussed after surgery when the treatment plan is clearer. The focus before surgery should be on preparing the child and family for the surgery itself.

B. Monitor blood pressure every 2 hours for hypertension: Wilm's tumor can be associated with hypertension due to renin production from the tumor, so monitoring the child's blood pressure closely is essential to detect any signs of hypertension early.

C. Provide parents with simple explanations and repeat often: Simplified, repeated explanations are key to helping parents understand the diagnosis and surgical procedure. This approach supports emotional comfort and ensures informed decision-making.

D. Attend all healthcare provider and parent conferences: While it is important to support the family, the nurse’s role in attending all healthcare provider and parent conferences is not mandatory unless specifically needed for continuity of care.

E. Measure the child's abdominal girth: Measuring abdominal girth is essential preoperatively to monitor for any abdominal changes, such as swelling or distension, which could indicate tumor growth or other complications related to the Wilm's tumor.