A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.
The nurse is reviewing the client’s medical records.
Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

Hyperglycemia

Anemia

Type 1 diabetes mellitus

Hypertension

Answer and Explanation

The Correct Answer is D

Choice A rationale

Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.

Choice B rationale

Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.

Choice C rationale

Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.

Choice D rationale

Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.

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Correct Answer is A

Explanation

Choice A rationale

The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.

Choice B rationale

Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.

Choice C rationale

Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.

Choice D rationale

Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.

A. Administer the insulin 30 minutes after breakfast along with the patient’s other routine medications. B. Administer the insulin at 0700. C. Administer the insulin at 0730. D. Administer the insulin when the breakfast tray arrives.

Correct Answer is C

Explanation

Choice A rationale

Administering the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.

Choice B rationale

Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.

Choice C rationale

Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.

Choice D rationale

Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.

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A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.The nurse is reviewing the client’s medical records.Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

Nursing Test Bank

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