A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.
Select the findings that require immediate attention.
Glasgow Coma Scale score
Client's self-monitoring of blood glucose
Bicarbonate level
Vaccess
Oxygen saturation
Blood pressure results
ECG findings
Sodium level
Correct Answer : A,C,F,G,H
Choice A rationale:
The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.
Choice C rationale:
The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.
Choice F rationale:
The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.
Choice G rationale:
The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.
Choice H rationale:
The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Discussing hyperglycemia manifestations is not specific to Addison's disease, as Addison's is characterized by hypoglycemia due to cortisol deficiency.
Choice B rationale
Teaching the parents about cortisol replacement therapy is essential in Addison's disease management. Cortisol deficiency is the primary issue, so educating on proper administration and monitoring is crucial.
Choice C rationale
Placing the child on a low-sodium diet is not recommended because Addison's disease often involves salt wasting, so adequate sodium intake is necessary.
Choice D rationale
Monitoring for fluid volume excess is more applicable to conditions like heart failure, not Addison's disease, which is associated with dehydration and hypovolemia.
Correct Answer is A
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.
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