in a disaster situation the nurse assessing a diabetic client on insulin assesses for all of the following except
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1. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

Correct answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.

2. When assessing a client's mobility status, the physical examination should start with:

Correct answer: A

Rationale: When assessing a client's mobility status, it is crucial to start by examining their gait. Gait assessment is usually conducted as the client walks into the room. Normal gait is described as smooth, flowing, and rhythmic without the need for assistive devices. Choices B, C, and D are incorrect as they do not represent the standard practice of beginning the assessment of mobility status with gait examination.

3. Which of these would be the most appropriate way to document a client's refusal of medication?

Correct answer: C

Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.

4. Which of these types of fluid output is not typically measured?

Correct answer: D

Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.

5. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

Correct answer: B

Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.

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