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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Moon face is a characteristic feature of Cushing’s syndrome, caused by fat deposition around the face due to increased cortisol levels.

Choice B rationale

Buffalo hump, or the accumulation of fat on the upper back, is another hallmark of Cushing’s syndrome, resulting from prolonged exposure to high cortisol levels.

Choice C rationale

Purple striations, or stretch marks, commonly appear on the abdomen, thighs, and breasts in Cushing’s syndrome, due to skin thinning and weakening from excess cortisol.

Choice D rationale

Hypertension is a common manifestation of Cushing’s syndrome because cortisol increases blood pressure through various mechanisms, including increased sensitivity to catecholamines. .

A. Obtain a wound culture B. Rapidly administer 30 mL/kg of normal saline C. Insert a nasogastric (NG) tube D. Obtain blood cultures E. Administer broad-spectrum antibiotics F. Measure lactate level G. Type and cross-match for 2 units of packed RBCs H. Obtain a urine specimen

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale:

Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.

Choice B rationale:

Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.

Choice D rationale:

Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.

Choice E rationale:

Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.

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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department. Exhibits Select the findings that require immediate attention.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Cushing's syndrome.The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a 73-year-old male client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Correct Answer is ["A","B","D","E"]

Explanation

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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.

Exhibits

Select the findings that require immediate attention.