An older adult who is a non-Hispanic Caucasian has a fasting blood sugar level above 130 mg/dL. Which client assessment does the nurse use to confirm a high risk for diabetes mellitus in the client?

Choice A reason: Controlling fluid balance is the most important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as fluid overload is the main cause of HF worsening and hospital admission. Fluid balance can be controlled by monitoring weight, intake and output, edema, and lung sounds, and by administering diuretics, restricting sodium and fluid intake, and elevating the legs.

Choice B reason: Controlling blood pressure is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as hypertension is a risk factor and a complication of HF. However, it is not the most important goal, as blood pressure may not always reflect the fluid status or the severity of HF. Blood pressure can be controlled by administering antihypertensive medications, such as angiotensin-converting enzyme inhibitors, beta-blockers, or calcium channel blockers, and by encouraging lifestyle modifications, such as smoking cessation, weight management, and stress reduction.

Choice C reason: Preventing deconditioning is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as deconditioning is a common problem in HF patients due to reduced physical activity, fatigue, and muscle wasting. However, it is not the most important goal, as deconditioning may not directly affect the fluid balance or the cardiac function. Deconditioning can be prevented by providing exercise training, such as aerobic, resistance, or interval training, and by promoting self-care and adherence to the treatment regimen.

Choice D reason: Maintaining client safety is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as HF patients are at risk of falls, injuries, infections, or adverse drug reactions. However, it is not the most important goal, as client safety may not specifically address the fluid balance or the cardiac function. Client safety can be maintained by providing a safe environment, such as removing clutter, providing adequate lighting, and using assistive devices, and by preventing complications, such as monitoring for signs of infection, bleeding, or electrolyte imbalance, and by educating the client and the family about the medications, the signs and symptoms of HF worsening, and the emergency measures.

Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.

Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.

Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.

Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.

Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.