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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.

A.

Glucose at 1130

B.

Client report of shakiness

C.

Temperature

D.

Heart rate

E.

SPO2

F.

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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Related Questions

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

A high white blood cell (WBC) count in cerebrospinal fluid (CSF) is more commonly associated with bacterial meningitis, characterized by a high neutrophil count, low glucose, and high protein levels. it is also seen in encephalitis and reflects the individual cell lines that are affected.

Muscle weakness and altered levels of consciousness can occur in both conditions but are more prominent in encephalitis, which often presents with focal neurological deficits and seizures. The

Kernig sign, a classical sign of meningitis, is a physical examination finding that indicates irritation of the meninges and supports a diagnosis of bacterial meningitis when positive.

An elevated body temperature is common in bacterial meningitis, but it is not exclusive and can be observed in encephalitis as well.

Correct Answer is C

Explanation

A. Pain-relieving medications may be appropriate for symptom management but do not address the need for diagnosis or treatment of gonorrhea exposure.
B. A basic metabolic panel (BMP) is not relevant to the diagnosis or management of gonorrhea. Testing for sexually transmitted infections (STIs) requires specific diagnostic tests.
C. Obtaining information about the client's recent sexual experiences is crucial for assessing risk factors, guiding testing, and determining appropriate treatment for gonorrhea.
D. A pelvic ultrasound is not typically the initial step in managing gonorrhea exposure. It might be used to assess complications but is not relevant for initial assessment or treatment.

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