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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Antinuclear antibody (ANA) is a test used to help diagnose autoimmune disorders, including RA. However, ANA is not typically used to monitor the effectiveness of treatment with aspirin in RA. Aspirin is an anti-inflammatory medication, and its effectiveness would not be directly measured by changes in ANA levels.
Choice B reason:
Erythrocyte sedimentation rate (ESR) is a blood test that can detect inflammation in the body and is commonly used to assess the severity of inflammation in patients with RA. Aspirin can reduce inflammation, so a decrease in ESR can indicate the effectiveness of aspirin therapy in managing RA symptoms.
Choice C reason:
Rheumatoid factor (RF) is an antibody that can be present in the blood of people with RA. While RF can be used to help diagnose RA, it is not typically used to monitor the effectiveness of aspirin therapy. RF levels can remain elevated even when symptoms are well-controlled.
Choice D reason:
White blood cell (WBC) count is a measure of the body's immune response and can be elevated in cases of infection or inflammation. However, WBC count is not specifically used to monitor the effectiveness of aspirin therapy in RA. Aspirin's primary effect is on reducing inflammation and pain, not necessarily on altering WBC counts.
Correct Answer is A
Explanation
Choice A reason:
Weight loss is a common finding in individuals with uncontrolled type 1 diabetes mellitus. Due to the lack of insulin, the body cannot utilize glucose effectively, leading to the breakdown of body fat and muscle for energy, resulting in weight loss.
Choice B reason:
Hematuria, or blood in the urine, is not a typical finding associated with uncontrolled type 1 diabetes mellitus. While diabetes can cause kidney damage over time, leading to proteinuria, hematuria would not be an expected finding solely due to uncontrolled diabetes.
Choice C reason:
Bradycardia, or a slower than normal heart rate, is not a common finding in uncontrolled type 1 diabetes mellitus. In fact, diabetes can sometimes cause autonomic neuropathy, which can affect the heart rate, but this typically does not result in bradycardia.
Choice D reason:
Hypertension is more commonly associated with type 2 diabetes mellitus, often due to insulin resistance. In type 1 diabetes, especially when uncontrolled, hypertension is not a typical finding unless there is coexisting kidney damage.
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