A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Assist the RN to prepare an intravenous (IV) insulin infusion.

Give the client 4 oz of orange juice.

Check the client's capillary blood glucose.

Assist the RN to administer 50% dextrose.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.

Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.

Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.

Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.

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Correct Answer is A

Explanation

Choice A Reason: Buffalo hump and moon face are physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, as they indicate fat redistribution and accumulation due to excess cortisol production.

Choice B Reason: Dry, scaly skin and cold intolerance are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hypothyroidism, which affects the metabolism and skin condition.

Choice C Reason: Dry, sticky mucous membranes and hypovolemia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate dehydration or diabetes insipidus, which affect the fluid balance and urine output.

Choice D Reason: Exophthalmos and tachycardia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hyperthyroidism, which affects the eye protrusion and heart rate.

A. Encourage deep-breathing exercises B. Provide a relaxing warm bath C. Schedule periods of rest in between activities D. Administer multivitamins

Correct Answer is C

Explanation

Choice A Reason: Encouraging deep-breathing exercises is not the most appropriate nursing intervention, as it may not reduce fatigue and may increase respiratory effort.

Choice B Reason: Providing a relaxing warm bath is not the most appropriate nursing intervention, as it may worsen fatigue and increase the risk of heat intolerance and dehydration.

Choice C Reason: Scheduling periods of rest in between activities is the most appropriate nursing intervention, as it helps to conserve energy, prevent exhaustion, and promote recovery.

Choice D Reason: Administering multivitamins is not the most appropriate nursing intervention, as it may not improve fatigue and may cause adverse effects or interactions with other medications.

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A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to a medical-surgical unit for surgery has a history of Cushing's syndrome. Which physical assessment finding would the nurse expect to observe?

Correct Answer is A

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