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:

B. Type 1 diabetes mellitus

The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.

Actions to Take:

B. Teach the client about the signs of hyperglycemia.
D. Assess the client’s feet for sensation.

Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.

Parameters to Monitor:

B. Blood pressure
D. Fingerstick blood glucose

Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.

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Correct Answer is []

Explanation

Potential Condition:

B. Type 1 diabetes mellitus

Actions to Take:

B. Teach the client about the signs of hyperglycemia.
D. Assess the client’s feet for sensation.

Parameters to Monitor:

B. Blood pressure
D. Fingerstick blood glucose

A. Call the Doctor. B. Administer diazepam. C. Obtain a medical history. D. Raise the side rails of the bed.

Correct Answer is B

Explanation

Choice A rationale

While it is important to notify the doctor, it is not the first action. The priority is to manage the patient’s symptoms and ensure their safety.

Choice B rationale

Administering diazepam is the correct first action. Delirium tremens is a severe form of alcohol withdrawal that can cause dangerous changes in breathing, blood pressure, and heart rate. Benzodiazepines like diazepam are the first line of treatment.

Choice C rationale

Obtaining a medical history is important, but it is not the first action. The priority is to treat the patient’s symptoms and stabilize their condition.

Choice D rationale

Raising the side rails of the bed is important for patient safety, but it is not the first action. The priority is to treat the patient’s symptoms. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse in the emergency department is implementing a plan of care for an older adult patient who is experiencing delirium tremens.What is the first action the nurse should take?

Correct Answer is B

Explanation

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