The nurse is developing a plan of care for a client who reports frequent urination and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client?
The client will express acceptance of their newly diagnosed health status.
The client's haemoglobin A1C will be less than 7.0% in 3 months.
The client's family will state signs and symptoms about the disease.
The nurse will monitor the client's skin condition for colour changes.
The Correct Answer is B
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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.
Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.
Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.
Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.
Correct Answer is A
Explanation
Choice A reason: Occult positive emesis, which indicates the presence of blood in vomit, is a critical finding. It suggests potential gastrointestinal bleeding, which requires immediate medical intervention. This condition can lead to significant blood loss and further complications if not addressed promptly.
Choice B reason: Strong foul-smelling flatus can indicate malabsorption or changes in gut flora, which are common after biliopancreatic diversion. While it can be unpleasant and concerning, it is not as immediately dangerous as gastrointestinal bleeding.
Choice C reason: A report of poor night vision could be related to vitamin A deficiency, which can occur after malabsorptive procedures like BPD. However, it is not an immediate threat compared to the risk of gastrointestinal bleeding.
Choice D reason: Loose bowel movements are common after BPD due to changes in digestion and absorption. While they can contribute to dehydration, they are not as urgent as the presence of blood in vomit.
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