A nurse is assessing a client who has diabetes mellitus and reports feeling dizzy and weak. Which of the following actions should the nurse take?
Check blood glucose level.
Give insulin injection.
Offer orange juice.
Apply cold compress.
The Correct Answer is A
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help reduce nausea and stimulate appetite. Frozen banana is cold, bland, and easy to digest, which are characteristics of antiemetic foods. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Correct Answer is B
Explanation
Choice A reason: Consuming ten percent of total calories from saturated fat is not a part of the DASH diet because it is too high for most adults. The DASH diet recommends consuming less than seven percent of total calories from saturated fat, which translates to about 16 g of saturated fat per day for an average adult who consumes 2,000 calories per day.
Choice B reason: Consuming foods that are high in calcium is a part of the DASH diet because it can help lower blood pressure by relaxing the blood vessels and reducing the force of contraction of the heart. The DASH diet recommends consuming 1,000 to 1,200 mg of calcium per day, which can be obtained from dairy products, leafy greens, beans, nuts, and fortified foods.
Choice C reason: Increasing intake of refined carbohydrates is not a part of the DASH diet because it can raise blood sugar and insulin levels, which can increase blood pressure and damage the blood vessels. The DASH diet recommends consuming 45 to 55 percent of total calories from carbohydrates, but mostly from whole grains, fruits, and vegetables, which are rich in fiber and antioxidants.
Choice D reason: Limiting sodium intake to 3,200 milligrams per day is not a part of the DASH diet because it is too high for most adults. The DASH diet recommends limiting sodium intake to 2,300 milligrams per day or less, which can help lower blood pressure by reducing fluid retention and vascular resistance.
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