The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow-up by the nurse?

Choice A reason: While it is important for the client to accept their new health status, this outcome is subjective and difficult to measure. The focus should be on specific, measurable outcomes related to diabetes management.

Choice B reason: A haemoglobin A1C level of less than 7.0% in 3 months is a specific, measurable outcome that indicates good control of blood glucose levels. It reflects adherence to the prescribed diabetic regimen and effective management of the condition.

Choice C reason: Educating the client's family about the signs and symptoms of diabetes is important, but it is more of a teaching objective rather than a measurable outcome for the client's plan of care.

Choice D reason: Monitoring the client's skin condition for colour changes is part of routine care but does not directly address the management of diabetes or measure the effectiveness of the treatment plan.

Choice A reason: Clay-coloured stool is a symptom of bile duct obstruction. It indicates that bile is not reaching the intestines to help digest food. While this is important to note, it is not the most urgent finding that requires immediate reporting to the healthcare provider.

Choice B reason: A distended, hard, and rigid abdomen is a sign of possible peritonitis or other severe abdominal complications. This finding indicates a medical emergency that requires immediate attention and intervention by the healthcare provider. Prompt reporting is essential to prevent further complications and ensure appropriate treatment.

Choice C reason: Bile-stained emesis suggests that bile is being regurgitated, which is indicative of a blocked or compromised bile duct. However, this finding does not require as urgent reporting as a rigid abdomen, which could indicate a more serious condition.

Choice D reason: Radiating, sharp pain in the right shoulder is often referred pain from gallbladder issues. While this symptom is significant and should be monitored, it does not take precedence over the urgent finding of a distended and rigid abdomen that might indicate a severe complication.