A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.

B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.

C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.

D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.

E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.

Rationale

A. Perform a vaginal examination every 12 hr: Vaginal examinations should be avoided in a client with severe preeclampsia unless delivery is imminent, as they can stimulate uterine activity and increase the risk of placental abruption. Continuous monitoring and noninvasive assessments are prioritized instead.

B. Administer betamethasone: Betamethasone promotes fetal lung maturity by stimulating surfactant production when preterm delivery before 34 weeks is anticipated. This reduces the risk of neonatal respiratory distress syndrome and intraventricular hemorrhage.

C. Provide a low-stimulation environment: A quiet, dimly lit environment helps minimize CNS stimulation, reducing the risk of seizure activity in clients with severe preeclampsia. Environmental stressors such as bright lights and loud noises should be avoided.

D. Maintain bed rest: Bed rest, particularly in the left lateral position, improves uteroplacental perfusion and reduces blood pressure by minimizing pressure on the vena cava. It also helps limit activity that could elevate BP further.

E. Obtain a 24-hr urine specimen: Collecting a 24-hour urine specimen allows accurate assessment of total protein excretion, which confirms the severity of preeclampsia. Proteinuria greater than 300 mg/24 hr indicates significant renal involvement.

F. Give antihypertensive medication: Antihypertensives such as labetalol or hydralazine help prevent maternal complications like stroke or heart failure from sustained severe hypertension while avoiding excessive BP reduction that could impair uteroplacental blood flow.

G. Monitor intake and output hourly: Close monitoring of intake and output detects early signs of renal compromise or fluid overload, which are common in preeclampsia. Accurate measurement helps guide safe fluid management and prevent pulmonary edema.