A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.

Exhibits

Select the 3 findings that require immediate follow-up.

Glucose at 1130

Client report of shakiness

Temperature

Heart rate

SPO2

HbA1c

Answer and Explanation

Correct Answer : A,B,D

A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.

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Correct Answer is B

Explanation

A. Checking the IV site for bleeding is important but should be done more frequently in a client with thrombocytopenia (low platelet count), as bleeding can occur unexpectedly.
B. Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
C. Checking for proteinuria is not directly related to thrombocytopenia or the risk of bleeding. It is more commonly associated with kidney function monitoring.
D. Obtaining body temperature readings is important for infection monitoring, but it does not directly address the risk associated with a low platelet count, which primarily concerns bleeding.

A. The client's depression most likely occurred prior to the disaster. B. The client is experiencing a common response following a disaster. C. The client is not able to appreciate the fact they survived the disaster. D. The client most likely feels guilty about actions they took during the disaster.

Correct Answer is B

Explanation

B. Experiencing depression following a disaster is a common response. Survivors often experience a range of emotional responses, including depression, due to the trauma and loss associated with the event.
A. The depression is more likely related to the traumatic event rather than a pre-existing condition.
C. While survivors may struggle with feelings of guilt or disbelief, the focus should be on understanding the depression as a response to the trauma experienced.
D. Although feelings of guilt may be present, it is more pertinent to address the depression as a common mental health issue following a traumatic event.

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A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus. Exhibits Select the 3 findings that require immediate follow-up.

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A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.

Exhibits

Select the 3 findings that require immediate follow-up.