A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL).

A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours.

A client who has Graves' disease with a heart rate of 100/min and reports tremors.

A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.

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Correct Answer is D

Explanation

The correct answer is: d. Hypoglycemia

Choice A reason:

Hyperglycemia: This statement is wrong because hyperglycemia typically presents with symptoms like increased thirst, frequent urination, and fatigue, not sweating and anxiety.

Choice B reason:

Nephropathy: This statement is wrong because nephropathy, a kidney complication, does not cause acute symptoms like sweating and anxiety. It usually presents with proteinuria and progressive kidney dysfunction.

Choice C reason:

Ketoacidosis: This statement is wrong because diabetic ketoacidosis usually presents with symptoms like fruity breath, nausea, vomiting, and deep, rapid breathing (Kussmaul respirations), not sweating and anxiety.

Choice D reason:

Hypoglycemia: This statement is correct because hypoglycemia is characterized by symptoms such as sweating, anxiety, palpitations, and confusion due to the release of adrenaline in response to low blood glucose levels.

A. The client should anticipate scheduling the procedure 5 days prior to menstruation. B. The client might experience diarrhea as a result of the procedure. C. The client should be on a liquid diet for 1 day following the procedure. D. The client might experience shoulder pain following the procedure.

Correct Answer is D

Explanation

Choice A reason:Scheduling the procedure five days before the expected menses would place it in the late proliferative phase, which risks missing ongoing menstrual bleeding and could coincide with implantation if the client ovulated early. Best practice is to perform the test after menstruation ends but before ovulation—usually within 12 days of the first day of the last period—to ensure the client is not pregnant.

Choice B reason:
Diarrhea is not a common side effect of HSG. The procedure involves the insertion of a dye into the uterine cavity to visualize the fallopian tubes and uterus via X-ray. While some discomfort, cramping, or spotting may occur, diarrhea is not typically expected.

Choice C reason:
There is no requirement for a client to be on a liquid diet following an HSG procedure. The client can usually resume normal activities and diet immediately after the procedure unless otherwise instructed by their healthcare provider.

Choice D reason:
Referred shoulder pain can occur when contrast fluid spills through a patent tube into the peritoneal cavity, irritating the diaphragm’s undersurface and eliciting pain perceived at the shoulder via the phrenic nerve. Clients should be advised this is normal, short-lived, and relieved by positioning or mild analgesics.

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A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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