Hinkle Ch.43 PrepU
When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day? -3 AM -5 AM -9 AM -7 AM
3 AM Explanation: During the dawn phenomenon, the patient has a relatively normal blood glucose level until about 3 AM, when the level begins to rise.
A female patient with diabetes who weighs 150 pounds has an ideal body weight of 118 pounds. She can lose 1 pound per week and drop her extra 32 pounds in approximately 8 months. To meet this goal, the nurse advises the patient to decrease her calories by: -3,500 per week. -2,000 per week. -3,000 per week. -2,500 per week.
3,500 per week. Explanation: A person needs to decrease caloric intake by 3,500 for each lb of weight that is lost. To lose 1 lb per week, a person would decrease his or her daily caloric intake by 500 calories (500 calories × 7 days = 3,500 calories = 1 lb).
The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively? -85% to 90% -10% to 20% -50% to 60% -25% to 40%
50% to 60% Explanation: One half to two thirds of the patient's usual morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery. The remainder is then administered after surgery.
A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site? -Take the ordered antibiotics before initiating treatment. -Change the needle every 3 days. -Wear sterile gloves when inserting the needle. -Use clean technique when changing the needle.
Change the needle every 3 days. Explanation: The nurse should teach the client to change the needle every 3 days to prevent infection. The client doesn't need to wear gloves when inserting the needle. Antibiotic therapy isn't necessary before initiating treatment. Sterile technique, not clean technique, is needed when changing the needle.
The nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. What is an important dietary consideration for the nurse to keep in mind? -Make sure breakfast is not delayed. -Delay dinner meal. -Provide fewest amount of carbohydrates at lunch meal. -Encourage midday snack.
Encourage midday snack. Explanation: Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 10 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.
For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? -Cool, clammy skin -Jugular vein distention -Increased urine osmolarity -Decreased serum sodium level
Increased urine osmolarity Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.
A 1200-calorie diet and exercise are prescribed for a client with newly diagnosed type 2 diabetes. The nurse is teaching the client about meal planning using exchange lists. The teaching is determined to be effective based on which statement by the client? "For dinner I ate.." -"a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." -"2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas in a garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon." -"2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda." -"4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion; 1 ounce low-fat cheese; 1 tablespoon mayonnaise; 1 cup fresh strawberry shortcake; and un
"For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." Explanation: There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. For example, 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1 cup watermelon; "free" items like diet soda are optional.
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it? -"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." -"If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." -"If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." -"I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated."
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Explanation: The client stating that he'll remain hydrated and pay attention to his eating, drinking, and voiding needs indicates understanding of HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of non-diet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
The nurse instructs the client with diabetes on self-care during days of illness. Which client statement indicates that teaching has been effective? Select all that apply. -"I will increase my intake of fluids." -"I will skip my diabetes medication for the day." -"I will test my blood sugar level every 3 to 4 hours." -"I will call the doctor if I have vomiting or diarrhea." -"I will eat soft foods if I cannot tolerate regular food."
"I will increase my intake of fluids." "I will test my blood sugar level every 3 to 4 hours." "I will call the doctor if I have vomiting or diarrhea." "I will eat soft foods if I cannot tolerate regular food." Explanation: During periods of illness, the client with diabetes should be instructed to increase the intake of fluids to prevent dehydration. The blood glucose level should be checked every 3 to 4 hours. The health care provider should be contacted if vomiting or diarrhea occurs as extreme fluid loss may cause dehydration. Soft foods should be substituted for regularly ingested foods if the regular meal plan cannot be followed. The client should be instructed to take regular diabetes medication as prescribed.
A client with type 2 diabetes has recently been prescribed acarbose, and the nurse is explaining how to take this medication. The teaching is determined to be effective based on which statement by the client? -"I will take this medication in the morning, with my first bite of breakfast." -"I will take this medication in the morning, 15 minutes before breakfast." -"This medication needs to be taken after the midday meal." -"It does not matter what time of day I take this medication."
"I will take this medication in the morning, with my first bite of breakfast." Explanation: Alpha-glucosidase inhibitors such as acarbose and miglitol, delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.
Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice? -"You should take your insulin after you eat breakfast and dinner." -"Your insulin will begin to act in 15 minutes." -"You should expect your insulin to reach its peak effectiveness by 12 noon if you take it at 8:00 AM." -"Your insulin will last 8 hours, and you will need to take it three times a day."
"You should take your insulin after you eat breakfast and dinner." Explanation: NPH (Humulin N) insulin is an intermediate-acting insulin that has an onset of 2 to 4 hours, a peak effectiveness of 6 to 8 hours, and a duration of 12 to 16 hours. See Table 30-3 in the text.
A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply. -"Insulin promotes synthesis of proteins in various body tissues." -"Insulin promotes the storage of fat in adipose tissue." -"Insulin permits entry of glucose into the cells of the body." -"Insulin interferes with glucagon from the pancreas." -"Insulin interferes with the release of growth hormone from the pituitary."
-"Insulin permits entry of glucose into the cells of the body." -"Insulin promotes synthesis of proteins in various body tissues." -"Insulin promotes the storage of fat in adipose tissue." Explanation: Insulin is a hormone secreted by the endocrine part of the pancreas. In addition to lowering blood glucose by permitting entry of glucose into the cells, insulin also promotes protein synthesis and the storage of fat in adipose tissue. Somatostatin exerts a hypoglycemic effect by interfering with glucagon from the pancreas and the release of growth hormone from the pituitary.
A client has been diagnosed with diabetes and discusses treatment strategies with the nurse. What consequences of untreated diabetes should the nurse include with client teaching? Select all that apply. -Kidney disease -Limb amputation -Blindness -Liver failure -Cardiovascular disease
-Blindness -Limb amputation -Cardiovascular disease -Kidney disease Explanation: The nurse should include blindness, limb amputation, cardiovascular disease, and kidney disease in the teaching of the consequences of untreated diabetes. Liver failure is not a known consequence of diabetes.
A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis. -Blurred or deteriorating vision -Wounds that heal slowly or respond poorly to treatment -Fatigue and irritability -Polyuria and polydipsia -Sudden weight loss and anorexia
-Blurred or deteriorating vision -Fatigue and irritability -Polyuria and polydipsia -Wounds that heal slowly or respond poorly to treatment Explanation: All the options are correct except for weight loss and anorexia. Obesity is almost always associated with type 2 diabetes.
The nurse is preparing an educational session about foot care for clients with diabetes. Which information will the nurse include in the education? Select all that apply. -Check the inside of shoes before putting them on. -Shave any calluses with a disposable razor. -Wear binding compression socks daily. -Apply lotion between the toes after bathing. -Check the bottom of the feet with a mirror every day.
-Check the inside of shoes before putting them on. -Check the bottom of the feet with a mirror every day. Explanation: The client with diabetes needs to be instructed on foot care in order to prevent the development of wounds. Information about foot care includes checking the inside of shoes before putting them on to ensure that there is nothing inside the shoe. The bottom of the feet should be checked every day and a mirror helps to visualize the bottom of the feet. The client should never go barefoot. Wearing binding compression socks would constrict the feet. The client with diabetes should wear well-fitted shoes. Calluses are not to be shaved as this could cause a wound. A podiatrist should be consulted for any calluses on the feet. Lotion is not to be applied between the toes after bathing since it can promote fungal growth due to moisture.
Which of the following is an age-related change that may affect diabetes? Select all that apply. -Decreased renal function -Increased bowel motility -Taste changes -Decreased vision -Increased proprioception
-Decreased renal function -Taste changes -Decreased vision Explanation: Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.
A client newly diagnosed with type 1 diabetes has an unusual increase in blood glucose from bedtime to morning. The physician suspects the client is experiencing insulin waning. Based on this diagnosis, the nurse expects which change to the client's medication regimen? -Decreasing evening bedtime dose of intermediate-acting insulin and administering a bedtime snack -Changing the time of evening injection of intermediate-acting insulin from dinnertime to bedtime -Administering a dose of intermediate-acting insulin before the evening meal -Increasing morning dose of long-acting insulin
Administering a dose of intermediate-acting insulin before the evening meal Explanation: Insulin waning is a progressive rise in blood glucose form bedtime to morning. Treatment includes increasing the evening (before dinner or bedtime) dose of intermediate-acting or long-acting insulin or instituting a dose of insulin before the evening meal if that is not already part of the treatment regimen.
A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two IV lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question? -Add 40 mEq potassium chloride to an infusion of half normal saline solution and infuse at a rate of 10 mEq/hour. -Infuse 500 ml of normal saline solution over 1 hour. -Hold insulin infusion for 30 minutes. -Change the second IV solution to dextrose 5% in water.
Change the second IV solution to dextrose 5% in water. Explanation: The nurse should question the physician's order to change the second IV solution to dextrose 5% in water. The client should receive normal saline solution through the second IV site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.
A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority? -Deficient fluid volume related to osmotic diuresis -Decreased cardiac output related to elevated heart rate -Imbalanced nutrition: Less than body requirements related to insulin deficiency -Ineffective thermoregulation related to dehydration
Deficient fluid volume related to osmotic diuresis Explanation: A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and fluid volume deficit, making Deficient fluid volume related to osmotic diuresis the highest priority. In this client, tachycardia is more likely to result from fluid volume deficit than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition: Less than body requirements isn't appropriate. A temperature of 100.6° F isn't life-threatening, eliminating Ineffective thermoregulation as the top priority.
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of: -Health-seeking behaviors (diabetes control). -Deficient knowledge (treatment regimen). -Impaired adjustment. -Defensive coping.
Deficient knowledge (treatment regimen). Explanation: The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.
A nurse is inspecting the feet of a client with diabetes and finds a tack sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding? -Nephropathy is a common complication of diabetes mellitus. -Motor neuropathy causes muscles to weaken and atrophy. -High blood sugar decreases blood circulation to nerves. -In diabetes, the autonomic nerves are affected.
High blood sugar decreases blood circulation to nerves. Explanation: Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness. Autonomic neuropathy is a complication of diabetes mellitus but not significant with peripheral injuries. Motor neuropathy does occur with poor glucose control but not specific to this injury. Nephropathy is a common complication that directly affects the kidneys.
An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing? -Systemic inflammatory response syndrome -Multiple-organ dysfunction syndrome -Diabetic ketoacidosis -Hyperglycemic hyperosmolar syndrome
Hyperglycemic hyperosmolar syndrome Explanation: Hyperglycemic hyperosmolar syndrome (HHS) occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes (Reynolds, 2012). The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis).
A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to: -Decrease the body's sensitivity to insulin. -Inhibit the production of glucose by the liver. -Increase the absorption of carbohydrates in the intestines. -Stimulate the beta cells of the pancreas to secrete insulin.
Inhibit the production of glucose by the liver. Explanation: The action of the biguanides can be found in Table 30-6 in the text.
A diabetic client using insulin reports weight gain. Which response from the nurse explains the most likely cause of the weight increase? -Faulty fat metabolism is shut off. -Weight gain is attributed to fluid retention. -Insulin provides more efficient use of glucose. -Insulin is an anabolic hormone.
Insulin is an anabolic hormone. Explanation: Insulin is an anabolic hormone that is known to cause weight gain. Insulin does lower blood glucose levels by allowing for active transport of glucose into the cells. Faulty fat and protein metabolism will cease once glucose provides the needed the fuel for energy. The restoration of normal metabolism is not the primary cause for weight gain in a client prescribed insulin. Fluid retention is not indicated in this client.
Which term refers to the progressive increase in blood glucose from bedtime to morning? -Dawn phenomenon -Somogyi effect -Insulin waning -Diabetic ketoacidosis (DKA)
Insulin waning Explanation: Insulin waning is a progressive rise in blood glucose from bedtime to morning. The dawn phenomenon occurs when blood glucose is relatively normal until about 3 a.m., when the level begins to rise. The Somogyi effect occurs when blood glucose is normal or elevated at bedtime, decreases at 2 to 3 a.m. to hypoglycemia levels, and subsequently increases as a result of the production of counter-regulatory hormones. DKA is caused by an absence or markedly inadequate amount of insulin. This insulin deficit results in disorders in the metabolism of carbohydrates, proteins, and fats. The primary clinical features of DKA are hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis.
A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which factor should the nurse monitor when caring for the client? -Allergic reactions -Low blood glucose concentration -Hypertonicity -Polyuria
Low blood glucose concentration Explanation: Clients who switch from animal to synthesized human insulin should initially be monitored for low blood glucose concentrations because the human form of insulin is used more effectively. Human insulin causes fewer allergic reactions than insulin obtained from animal sources. Polyuria and hypertonicity are symptoms of diabetes mellitus.
The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply. -May reduce postprandial glucose levels -Decrease the need for exogenous insulin -Help reduce cholesterol levels -May improve blood glucose levels -Increase potassium levels
May improve blood glucose levels Decrease the need for exogenous insulin Help reduce cholesterol levels Explanation: Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood (ADA, 2008b; Geil, 2008).
A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom? -Altered mental state -Muscle wasting and tissue loss -Weight gain -Dehydration
Muscle wasting and tissue loss Explanation: Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although clients with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.
A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply. -Increase in blood glucose from 3:00 AM until breakfast -Rise in blood glucose about 11:00 AM -Normal bedtime blood glucose -Elevated blood glucose at bedtime -Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM
Normal bedtime blood glucose Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM Explanation: The Somogyi effect is nocturnal hypoglycemia followed by rebound hyperglycemia in the morning.
Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus? -Patient's ability to self-administer insulin -Patient's history -Patient's eating and sleeping habits -Cognitive problems
Patient's eating and sleeping habits Explanation: The eating and sleeping habits of older adults differ from those of young or middle-aged persons. The nurse should take this into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent. The nurse should evaluate the patient's ability to self-administer insulin before developing a teaching program. Cognitive problems and patient history may not be taken into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent.
A client newly diagnosed with type 1 diabetes asks the nurse why injection site rotation is important. What is the nurse's best response? -Promote absorption. -Avoid infection. -Minimize discomfort. -Prevent muscle destruction.
Promote absorption. Explanation: Subcutaneous injection sites require rotation to avoid breakdown and/or buildup of subcutaneous fat, either of which can interfere with insulin absorption in the tissue. Infection and discomfort are risks involved with injection site but not the primary reason for rotation of sites. Insulin is not injected into the muscle.
A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan? -Maintenance of blood glucose levels between 180 and 200 mg/dl -Smoking reduction but not complete cessation -An eye examination every 2 years until age 50 -Weight reduction through diet and exercise
Weight reduction through diet and exercise Explanation: Type 2 diabetes is commonly obesity-related; therefore, weight reduction may enhance the normalization of the blood glucose level. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained within normal limits to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes shouldn't smoke at all because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy.
Which of the following medications is considered a glitazone? -metformin with glyburide -metformin -pioglitazone -dapagliflozin
pioglitazone Explanation: Pioglitazone and rosiglitazone are classified as a glitazone or thiazolidinedione. Metformin and metformin with glyburide are classified as biguanides. Dapagliflozin is classified as a sodium-glucose co-transporter 2 (SGL-2) inhibitor.
A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy via an insulin pump. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of: -intermediate- and long-acting insulins. -short- and long-acting insulins. -rapid-acting insulin only. -short- and intermediate-acting insulins.
rapid-acting insulin only. Explanation: A continuous subcutaneous insulin regimen uses a basal rate and boluses of rapid-acting insulin. Multiple daily injection therapy uses a combination of rapid-acting and intermediate- or long-acting insulins.
A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to: -provide time for privacy. -encourage the client to ask questions about personal sexuality. -suggest referral to a sex counselor or other appropriate professional. -provide support for the spouse or significant other.
suggest referral to a sex counselor or other appropriate professional. Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.
