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

Measure pulse and blood pressure

Document anxiety on the surgical checklist

Assess skin temperature and moisture

Check fingerstick glucose level

Administer a PRN dose of regular insulin

Answer and Explanation

Correct Answer : A,C,D,E

A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.

B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.

C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.

D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.

E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.

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Correct Answer is D

Explanation

A. Thick skin plaques topped by silvery white scales:
This is a characteristic presentation of psoriasis vulgaris, not an indicator of overexposure to PUVA.

B. Tenderness upon palpation and generalized erythema:
This may be associated with various skin conditions but is not specific to overexposure to PUVA.

C. Brown, rough, greasy, wart-like papules on the face:
This description is not consistent with the expected outcomes or side effects of PUVA treatment.

D. Requires sunglasses because sunlight hurts the eyes.
PUVA treatment involves the use of psoralen, a light-sensitizing medication, followed by exposure to ultraviolet A (UVA) light. Overexposure to PUVA can lead to phototoxic reactions, including eye sensitivity to sunlight (photophobia). If the client requires sunglasses because sunlight hurts the eyes, it suggests that the eyes have been affected by the treatment, and the nurse should intervene to prevent further damage.

A. Skin elasticity. B. Urinary output. C. Oxygen saturation. D. Lung sounds. E. Pain scale.

Correct Answer is ["B","C","D"]

Explanation

A. Skin elasticity:
Assessing skin elasticity is a measure of hydration status. Improved skin turgor may suggest that the client is responding positively to diuretic therapy by eliminating excess fluid. However, this may not be as immediate or specific as other indicators of response.

B. Urinary output:
Monitoring urinary output is crucial when administering diuretics like furosemide. Increased urine output indicates that the diuretic is promoting the elimination of excess fluid from the body, which is a desired effect in managing heart failure and fluid overload.

C. Oxygen saturation:
Assessing oxygen saturation is important in monitoring respiratory status. Improvement in oxygen saturation levels indicates that the client is responding to interventions aimed at relieving respiratory distress, such as the administration of furosemide.

D. Lung sounds:
Monitoring lung sounds is a key aspect of assessing respiratory function. Reduction in wheezes and crackles suggests that the diuretic is helping to alleviate pulmonary congestion and fluid accumulation in the lungs, contributing to improved respiratory function.

E. Pain scale:
Assessing pain is relevant if the client has reported chest pain or discomfort associated with heart failure. Reduction in pain may indicate improved cardiac function and response to treatment. However, it's important to note that pain assessment may not be as specific to the effects of furosemide as other respiratory and fluid status indicators.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Correct Answer is D

Explanation

Correct Answer is ["B","C","D"]

Explanation

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