A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?
Blood glucose using a glucometer
Pupillary reaction to light
Deep tendon reflexes
Liver function laboratory values
The Correct Answer is A
Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.
Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.
Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.
Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Placing the client in a private room is a correct action, because it reduces the exposure of other clients and staff to the radiation source.
Choice B reason: Securing a dosimeter badge to the client's gown is an incorrect action, because the dosimeter badge is used to measure the radiation exposure of the staff, not the client. The client should wear an identification bracelet that indicates the type and location of the radiation source.
Choice C reason: Donning a cover gown before entering the client's room is a correct action, because it protects the nurse's clothing from contamination by the client's body fluids or secretions.
Choice D reason: Disposing of dislodged implants in a biohazard sharps container is a correct action, because it prevents the spread of radiation and infection. The nurse should also notify the radiation safety officer if an implant is dislodged.
Correct Answer is C
Explanation
Choice A reason: This is a vague and unhelpful response, because it does not provide any information or reassurance to the client who has a new diagnosis of MS. The nurse should explain the general course of MS and the possible variations among clients.
Choice B reason: This is a sympathetic but incomplete response, because it does not address the client's question or provide any information about the course of MS. The nurse should acknowledge the client's feelings and provide factual and realistic information.
Choice C reason: This is the best response, because it provides accurate and relevant information about the course of MS, which is a chronic and progressive disease that affects the central nervous system. MS can cause acute episodes of neurological symptoms, such as vision loss, numbness, weakness, or fatigue, which are followed by periods of remission, when the symptoms improve or disappear. The length and frequency of the episodes and remissions can vary among clients.
Choice D reason: This is a dismissive and unrealistic response, because it does not answer the client's question or respect the client's right to know about the course of MS. The nurse should not avoid the client's concerns or minimize the impact of the diagnosis. The nurse should help the client cope with the uncertainty and plan for the future.
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