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

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement is to measure the patient's pulse and blood pressure (Option C). This is crucial because the patient is experiencing symptoms of weakness and jitteriness, which could indicate hypoglycemia, a common complication in diabetes management. Checking the pulse and blood pressure can help assess the patient's hemodynamic status and provide valuable information about his overall condition. Option A (Checking his fingerstick glucose level) could also be important in this situation to confirm if the patient's symptoms are indeed related to hypoglycemia. However, measuring the pulse and blood pressure takes precedence as it provides immediate data on the patient's cardiovascular status, especially during a perioperative period. Options B (Assessing his skin temperature and moisture) and D (Documenting anxiety on the surgical checklist) are not the most appropriate actions to take in response to the patient's symptoms. While assessing skin temperature and moisture can provide some information about the patient's perfusion status, it may not directly address the immediate concern of weakness and jitteriness. Documenting anxiety, although important for holistic care, does not address the physiological symptoms the patient is experiencing and should not be the priority in this situation. From an educational perspective, this scenario highlights the importance of prioritizing nursing actions based on the patient's presenting symptoms and clinical context. Understanding the significance of assessing vital signs in a timely manner, especially in patients with comorbid conditions like diabetes, is crucial for providing safe and effective care. It also underscores the need for nurses to be adept at recognizing and managing potential complications in patients with chronic illnesses undergoing surgical procedures.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Pain. The probable etiology of the male client's difficulty sleeping is pain caused by Herpes zoster (shingles) lesions on his thorax. Pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. This pain can disrupt the client's ability to fall asleep or stay asleep, leading to sleep disturbances. Option B) Nocturia, which is excessive urination at night, is not likely to be the cause of the client's sleep difficulty in this case. Option C) Dyspnea, which is difficulty breathing, and Option D) Frequent cough are also not relevant to the client's complaint of difficulty sleeping due to shingles-related pain. Educationally, understanding the impact of pain on sleep is crucial for nurses caring for clients with conditions like Herpes zoster. Nurses need to assess and manage pain effectively to promote quality sleep, which is essential for the client's overall well-being and recovery. By recognizing pain as a potential barrier to sleep, nurses can implement appropriate interventions to improve the client's comfort and rest.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: "Observe for prolonged periods of apnea." The nurse's first priority during a seizure is to ensure the client's airway remains clear and that they are breathing adequately. Prolonged periods of apnea can lead to hypoxia, which can be life-threatening. By closely monitoring the client's breathing, the nurse can intervene promptly if respiratory distress occurs. Option A, documenting details of the seizure activity, is important for the client's medical record but is not the most immediate concern during an active seizure. Option B, observing for lacerations to the tongue, is important post-seizure to assess for injuries but is not the priority during the seizure itself. Option D, evaluating for evidence of incontinence, is also a secondary concern compared to ensuring the client's airway and breathing are stable. In an educational context, this question highlights the critical importance of prioritizing interventions during a medical emergency like a seizure. Nurses must be prepared to act quickly and decisively to ensure the safety and well-being of their clients, especially when faced with unexpected situations. Understanding the priorities of care during a seizure is crucial knowledge for nurses working in various healthcare settings, including pediatric nursing where seizures can occur.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to implement is to select option B: Obtain a specimen of urethral drainage for culture. This is the most appropriate initial action as the client is presenting with symptoms suggestive of a possible urinary tract infection (UTI) or a sexually transmitted infection (STI) following unprotected sexual intercourse. By obtaining a specimen for culture, the nurse can identify the causative organism and guide appropriate treatment. Option A, observing the perineal area for a chancroid-like lesion, is incorrect because the client's symptoms do not specifically suggest the presence of a chancroid lesion, and obtaining a urethral culture is a more direct way to diagnose a possible infection. Option C, assessing for perineal itching, erythema, and excoriation, while relevant, does not address the need for a definitive diagnosis through a urethral culture. Option D, identifying all sexual partners in the last four days, is important for contact tracing and counseling but is not the immediate priority in this situation. From an educational standpoint, this question highlights the importance of thorough assessment and appropriate interventions in clients presenting with genitourinary symptoms following sexual activity. It emphasizes the need for nurses to consider both UTIs and STIs in the differential diagnosis and to prioritize diagnostic testing to guide treatment decisions effectively.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fluid output (Option C). This is the most appropriate response because after a paracentesis, it is essential to monitor the drainage output to assess the client's response to the procedure and to watch for any signs of complications. Option A, palpating for abdominal distention, is not the priority in this situation as monitoring fluid output takes precedence to ensure proper drainage and assess for complications. Option B, sending the fluid to the lab for analysis, may be necessary at some point, but the immediate action should be to monitor the fluid output to ensure proper drainage and assess for any immediate concerns. Option D, clamping the drainage tube for 5 minutes, is not recommended as it may lead to a potential buildup of fluid in the abdomen, which could result in discomfort and complications for the client. From an educational standpoint, understanding the importance of monitoring post-procedural drainage output is crucial in pediatric nursing, especially in cases like ascites where fluid removal plays a significant role in managing the client's condition. Nurses must prioritize ongoing assessment and monitoring to ensure optimal patient outcomes and prevent potential complications.