A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?
The client refuses breakfast and requests to sleep.
The client asks the AP to trim his broken toenail.
The client reports urine that is dark yellow in color.
The client reports dizziness when standing.
The Correct Answer is A
Choice A rationale:
Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin. Insulin is a hormone that helps the body to use glucose for energy. Glucose is a sugar that comes, in large part, from foods we eat. Insulin allows glucose to enter cells in the body. Therefore, if a client with type 1 diabetes refuses breakfast and requests to sleep, it could lead to hypoglycemia, a condition characterized by abnormally low blood glucose levels. Hypoglycemia can cause symptoms such as weakness, sweating, confusion, and in severe cases, unconsciousness or seizures. It is a medical emergency and should be reported immediately.
Choice B rationale:
Trimming a toenail may seem like a simple task, but for a person with diabetes, it can lead to serious complications. Diabetes can cause nerve damage that leads to numbness in the feet, making it difficult for a person to feel a cut, blister, or sore. These injuries can become infected and lead to serious complications, such as the need for amputation. However, this situation is not as immediately life-threatening as hypoglycemia and does not need to be reported immediately.
Choice C rationale:
Dark yellow urine can be a sign of dehydration, which can be a concern for individuals with diabetes. However, it can also be a result of less serious causes such as certain medications, foods, or simply not drinking enough fluids. While it’s important for the AP to encourage the client to drink more fluids, this situation is not as immediately life-threatening as hypoglycemia.
Choice D rationale:
Dizziness when standing, also known as orthostatic hypotension, can be a side effect of some medications used to treat diabetes. It can also be a symptom of dehydration or other conditions. While it’s important for the AP to monitor the client’s symptoms and report any changes, this situation is not as immediately life-threatening as hypoglycemia
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acyclovir is an antiviral medication used to treat infections caused by certain types of viruses. It is primarily used for the treatment of herpes simplex virus infections, chickenpox, and shingles. However, it is not typically used as an anti-HIV drug.
Choice B rationale:
Ribavirin is an antiviral medication used to treat hepatitis C and certain other viral infections. While it has broad-spectrum antiviral activity, it is not specifically used to prevent mother-to-child transmission of HIV.
Choice C rationale:
Foscarnet is an antiviral medication used to treat or prevent cytomegalovirus (CMV) retinitis in individuals with AIDS. It is also used to treat cold sores and genital herpes. However, it is not the first-line choice for preventing mother-to-child transmission of HIV.
Choice D rationale:
Zidovudine, also known as AZT, is an antiretroviral medication used to prevent and treat HIV/AIDS. It is generally safe for use during pregnancy and is commonly used to prevent mother-to-child transmission of HIV12. It works by inhibiting the reverse transcriptase enzyme, thereby blocking viral replication. The use of Zidovudine and other antiretroviral drugs in pregnant women with HIV has significantly reduced the rate of mother-to-child transmission of the virus.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Polyuria, which is frequent or excessive urination, is not typically a symptom of hypoglycemia. It is more commonly associated with hyperglycemia, or high blood sugar levels.
Choice B rationale:
Sweating is indeed a common symptom of hypoglycemia. When blood sugar levels fall too low, the body may respond by sweating as it releases adrenaline in response to the hypoglycemic state.
Choice C rationale:
Tachycardia, or a fast heartbeat, is another common symptom of hypoglycemia. This is part of the body’s response to low blood sugar levels, as it releases adrenaline to try to raise these levels.
Choice D rationale:
Blurry vision can be a symptom of hypoglycemia. When blood sugar levels fall, it can affect the ability of the eyes to focus, leading to blurry vision.
Choice E rationale:
Polydipsia, or excessive thirst, is not typically a symptom of hypoglycemia. Like polyuria, it is more commonly associated with hyperglycemia.
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