A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition Most Likely Experiencing:
- Type 1 diabetes
Actions to Take:
- Teach the client about the signs of hyperglycemia.
- Assess the client’s feet for sensation.
Parameters to Monitor:
- Fingerstick blood glucose
- Blood pressure
Rationale: The client has a high HbA1c (8.4%) and elevated blood glucose level (235 mg/dL), indicating poor blood glucose control. Symptoms such as fatigue, blurred vision, and dizziness suggest hyperglycemia, which can occur in clients with diabetes who have not been able to maintain regular glucose monitoring or insulin administration due to financial constraints. Teaching the client about hyperglycemia symptoms and checking feet for sensation is important due to the risk of complications like neuropathy. Monitoring blood glucose and blood pressure is essential for evaluating diabetes management and preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Maintaining bed rest is not typically required after an IVP unless otherwise indicated for the patient's condition.
B. Administering a laxative is not a standard intervention following an IVP unless the patient specifically requires it for bowel preparation or constipation.
C. Encouraging adequate fluid intake is crucial after the administration of contrast medium to help flush the kidneys and minimize the risk of contrast-induced nephropathy.
D. While assessing for hematuria may be appropriate, it is not a primary intervention directly related to the IVP procedure itself.
Correct Answer is B
Explanation
A. Giving carbohydrates at 3:00 AM might prevent hypoglycemia temporarily but does not address the underlying issue.
B. Having a snack at bedtime helps prevent nighttime hypoglycemia, which can lead to rebound hyperglycemia, known as the Somogyi effect.
C. Increasing the insulin dose could exacerbate nocturnal hypoglycemia, worsening the Somogyi effect.
D. Doing nothing is inappropriate as the low 2:00 AM glucose level is a sign of the Somogyi effect.
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