Answer to Question 1
1,3,5
Rationale 1: This patient will most likely require a total bed bath.
Rationale 2: This patient is not likely to tolerate walking.
Rationale 3: This patient may not be able to initiate frequent moving in bed, so the nurse must intervene.
Rationale 4: The patient will not be able to participate in weight-bearing exercises.
Rationale 5: The patient may have difficulty feeding self, so monitoring and assistance are indicated.
Global Rationale: This patient will most likely require a total bed bath. This patient may not be able to initiate frequent moving in bed, so the nurse must intervene. The patient may have difficulty feeding self, so monitoring and assistance are indicated. This patient is not likely to tolerate walking. The patient will not be able to participate in weight-bearing exercises.
Answer to Question 2
2
Rationale 1: Phenytoin (Dilantin) can increase serum glucose levels, not decrease them.
Rationale 2: Phenytoin (Dilantin) can increase serum glucose levels, and the patient may need additional insulin.
Rationale 3: All patients receiving phenytoin (Dilantin) are at risk for petechiae, epistaxis, and hematuria; this is not specific to the patient with type 1 diabetes mellitus.
Rationale 4: All patients receiving phenytoin (Dilantin) are at risk for dizziness and ataxia; this is not specific to the patient with type 1 diabetes mellitus.
Global Rationale: Phenytoin (Dilantin) can increase serum glucose levels, and the patient may need additional insulin. All patients receiving phenytoin (Dilantin) are at risk for dizziness and ataxia; this is not specific to the patient with type 1 diabetes mellitus. All patients receiving phenytoin (Dilantin) are at risk for petechiae, epistaxis, and hematuria; this is not specific to the patient with type 1 diabetes mellitus. Phenytoin (Dilantin) can increase serum glucose levels, not decrease them.