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A nurse is caring for a 58-year-old client admitted with reports of increased urination and thirst.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's 
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Sodium level: The client's sodium level is significantly elevated (157 mEq/L), indicating hyponatremia. This is a critical finding that needs to be addressed promptly to prevent serious complications such as seizures and coma.

Heart rate: While the heart rate is slightly elevated, it is not as urgent a concern as the sodium level. Once the sodium level is stabilized, the nurse can address the heart rate if it remains elevated.


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Related Questions

Correct Answer is D

Explanation

A. DKA occurs due to a significant deficiency of insulin rather than issues with cell response to insulin. The condition leads to high blood glucose and ketone production because there is not enough insulin to regulate glucose levels effectively.
B. DKA is primarily associated with diabetes mellitus type 1, not type 2. It can occur due to a lack of insulin and is not solely caused by illness, although illness can exacerbate it.
C. DKA is not limited to clients with diabetes mellitus type 1 who experience septic shock. It can occur in anyone with type 1 diabetes due to severe insulin deficiency, though septic shock can complicate the condition.
D. DKA results from a complete absence of insulin, which is characteristic of poorly controlled or undiagnosed diabetes mellitus type 1. This insulin deficiency leads to elevated blood glucose levels and ketone formation.

Correct Answer is D

Explanation

A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.

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