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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.

Exhibits



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.

Answer and Explanation

The Correct Answer is []

Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.

Actions to Take:

Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.

Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.

Parameters to Monitor:

Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.

Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.


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Related Questions

Correct Answer is C

Explanation

A. Moist mucous membranes would indicate adequate hydration, which is not typically seen in diabetes insipidus.

B. Bounding peripheral pulses are associated with conditions of fluid overload, not diabetes insipidus.

C. Poor skin turgor is a sign of dehydration, which is a common finding in diabetes insipidus due to excessive urine output leading to significant fluid loss.

D. Bradycardia is not typically associated with diabetes insipidus; tachycardia might be seen due to dehydration and hypovolemia.

Correct Answer is ["A","B","D","E"]

Explanation

Rationale:

A. Purple striae (stretch marks) are common in Cushing's syndrome due to skin thinning and the redistribution of fat.

B. A "moon face" is a classic sign of Cushing's syndrome, caused by fat deposition in the face.

C. Bronze pigmentation is associated with Addison's disease, not Cushing's syndrome.

D. A "buffalo hump," or fat accumulation on the upper back, is another characteristic feature of Cushing's syndrome.

E. Poor wound healing is expected in Cushing's syndrome due to the effects of prolonged exposure to high cortisol levels, which impair immune function and tissue repair.

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