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 D
Explanation
Choice A reason: 1 cup of brown rice contains about 84 mg of potassium, which is low compared to other foods.
Choice B reason: One medium raw tomato contains about 292 mg of potassium, which is moderate compared to other foods.
Choice C reason: 1 oz of cheddar cheese contains about 28 mg of potassium, which is very low compared to other foods.
Choice D reason: One small baked potato contains about 738 mg of potassium, which is very high compared to other foods. Potassium is important for nerve and muscle function, but too much can cause irregular heartbeat, muscle weakness, and nausea.
Correct Answer is D
Explanation
Choice A reason: BMI of 18.5 is at the lower end of the normal range (18.5-24.9), but it does not indicate severe malnutrition.
Choice B reason: Potassium 3.7 mEq/L is within the normal range (3.5-5.0), and it does not indicate electrolyte imbalance due to malnutrition.
Choice C reason: Phosphorus 3.5 mg/dL is within the normal range (2.5-4.5), and it does not indicate mineral deficiency due to malnutrition.
Choice D reason: Albumin 2.5 g/dL is below the normal range (3.5-5.0), and it indicates protein deficiency due to malnutrition. Albumin is a major protein in blood plasma that helps maintain fluid balance, transport hormones, and fight infections. Low albumin levels can cause edema, weakness, infection, and poor wound healing.
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