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: Tuna fish is a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is soft, moist, and easy to swallow. Tuna fish also provides protein, omega-3 fatty acids, and vitamin D for the client.
Choice B reason: Roast beef is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has missing teeth. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
Choice C reason: Apple slices are not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are crisp, firm, and sticky. Apple slices can cause irritation or injury to the gums or mouth or dislodge any remaining teeth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Choice D reason: Dried fruit is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are chewy, sticky, and sugary. Dried fruit can adhere to the gums or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
Correct Answer is B
Explanation
Choice A reason: Recommending a total fiber intake of 12 g each day is not an appropriate action for the nurse to take because it is too low for most adults. The recommended dietary allowance (RDA. for fiber is 25 g per day for women and 38 g per day for men, which can help lower cholesterol, regulate blood sugar, and promote bowel health.
Choice B reason: Referring the client to a weight-loss support group is an appropriate action for the nurse to take because it can help the client achieve and maintain a healthy weight. A body mass index (BMI) of 28 indicates overweight, which can increase the risk of chronic diseases, such as diabetes, hypertension, and cardiovascular disease. A weight-loss support group can provide education, motivation, and accountability for the client.
Choice C reason: Advising the client to add 500 calories per day to the diet is not an appropriate action for the nurse to take because it can lead to weight gain. A client who has a BMI of 28 does not need to increase their caloric intake unless they have other medical conditions or nutritional needs that require more calories. Adding 500 calories per day to the diet can result in gaining about one pound per week, which can worsen the health outcomes of the client.
Choice D reason: Encouraging the client to continue current daily caloric intake is not an appropriate action for the nurse to take because it may prevent weight loss. A client who has a BMI of 28 needs to reduce their caloric intake by 500 to 1,000 calories per day to lose one to two pounds per week, which is considered a safe and effective rate of weight loss.
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