A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6 hours are prescribed. What actions should the nurse include in this client's plan of care?

Correct Answer: D

Rationale: In managing a client with type 2 diabetes mellitus who is experiencing frequent hyperglycemic episodes with a high A1C level, a comprehensive plan of care is crucial. The correct answer, D) All of the above, is the most appropriate choice because it encompasses all the essential components needed for effective diabetes management in this scenario. Teaching subcutaneous injection technique, site rotation, and insulin management (Option A) is essential to ensure the client can self-administer insulin effectively, which is critical for glycemic control. Coordinating carbohydrate-controlled meals at consistent times and intervals (Option B) is vital to help regulate blood sugar levels and prevent further hyperglycemic episodes. Reviewing proper foot care and injury prevention (Option C) is important as diabetes can lead to neuropathy and poor wound healing, increasing the risk of foot complications. Options A, B, and C are not standalone interventions but rather complementary elements of a holistic diabetes management plan. By combining these actions, the nurse can address various aspects of the client's care, promoting better outcomes and quality of life. Educating the client on these aspects empowers them to actively participate in their care, leading to improved self-management and overall health. This question highlights the importance of a multidimensional approach to diabetes care, emphasizing the need for education, lifestyle modifications, and preventive measures to address the complex needs of individuals with diabetes. It underscores the role of nurses in educating and supporting clients with diabetes to achieve optimal health outcomes.

Correct Answer: B

Rationale: In the context of administering a proton pump inhibitor (PPI), the correct action to evaluate the effectiveness of the medication is to ask the client about gastrointestinal pain (Option B). This is because PPIs work by reducing the production of stomach acid, which helps in alleviating symptoms such as heartburn, acid reflux, and stomach ulcers. Therefore, asking the client about any improvement in gastrointestinal pain will provide direct feedback on the medication's efficacy. Monitoring bowel movements (Option A) is not directly related to evaluating the effectiveness of a PPI. Vital signs (Option C) may not reflect the specific symptom relief associated with PPI use. Assessing for signs of bleeding (Option D) is important when using medications like nonsteroidal anti-inflammatory drugs (NSAIDs) but is not the primary indicator of PPI effectiveness. In an educational context, understanding the rationale behind evaluating the effectiveness of medications is crucial for nurses to provide quality patient care. By linking the mechanism of action of a medication with the assessment of specific symptoms, nurses can make informed clinical decisions and ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct intervention is to complete the abnormal involuntary movement scale (AIMS) for the client. The client is exhibiting signs of tardive dyskinesia, a potential side effect of antipsychotic medications like haloperidol. AIMS is a standardized tool used to assess and monitor movement disorders, including tardive dyskinesia. By completing the AIMS assessment, the nurse can objectively evaluate the severity of the client's symptoms and determine the necessity for further intervention or medication adjustments. Discontinuing the medication immediately (Option A) is not recommended without proper assessment and evaluation of the client's symptoms. Abruptly stopping antipsychotic medications can lead to withdrawal symptoms and exacerbation of underlying psychiatric conditions. Increasing the dose of haloperidol (Option B) would be contraindicated as the client is already experiencing extrapyramidal side effects. Increasing the dose can further worsen these symptoms. Monitoring the client for signs of agitation (Option D) is important in general care but does not address the specific issue of tardive dyskinesia. Without proper assessment using the AIMS tool, the nurse may miss the opportunity to address the side effects effectively. Educationally, this scenario highlights the importance of thorough assessment, using appropriate tools, and understanding the side effects of medications in psychiatric nursing practice. It emphasizes the need for a systematic approach to managing medication side effects to ensure optimal client care and safety.

Correct Answer: A

Rationale: In this scenario, the most important finding to report to the healthcare provider is option A) Serum creatinine of 2.0 mg/dL. This is indicative of acute kidney injury (AKI), a serious complication often seen in clients with systemic inflammatory response syndrome (SIRS). AKI can result from poor perfusion due to the client's elevated heart rate and low blood pressure, leading to organ damage and failure if not addressed promptly. Option B) Elevated WBC count is a common finding in clients with SIRS and does not provide specific information regarding organ function or perfusion status. Option C) Blood pressure of 100/60 mmHg is low but expected in clients with SIRS and may not directly indicate organ dysfunction. Option D) Oxygen saturation of 95% is within normal range and does not alert to a critical issue necessitating immediate attention. Educationally, understanding the significance of laboratory values in the context of a client's condition is crucial for nurses to prioritize and communicate effectively with the healthcare team. Recognizing the implications of abnormal findings like elevated serum creatinine levels can guide timely interventions and prevent further deterioration in clients with complex health conditions.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) This is a common newborn rash that will resolve after several days. This response is accurate because the description of a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen is indicative of erythema toxicum, a benign and self-limiting rash commonly seen in newborns. It typically appears in the first few days of life and resolves on its own without any treatment. Option A) We need to monitor the rash for signs of worsening or fever is incorrect because erythema toxicum is a harmless condition and does not require monitoring for worsening or fever. Option B) Your baby may have an allergic reaction to laundry detergent is incorrect as this type of rash does not indicate an allergic reaction to laundry detergent. It is a common and harmless skin condition in newborns. Option D) This is likely a bacterial infection requiring antibiotics is incorrect as erythema toxicum is not caused by a bacterial infection and does not necessitate antibiotic treatment. From an educational perspective, it is crucial for nurses to be able to differentiate between common newborn rashes to provide accurate information and reassure parents. Understanding the characteristics, causes, and management of common newborn rashes like erythema toxicum is essential for providing quality care and guidance to parents of newborns.