After change-of-shift report, which patient will the nurse assess first?
A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain
A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output
A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon
The Correct Answer is C
Choice A reason: A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain is not the most urgent patient to assess. Peripheral neuropathy is a complication of diabetes that affects the nerves, especially in the feet and legs. It can cause symptoms such as numbness, tingling, burning, or pain. The nurse should assess the patient's foot condition, provide pain relief, and educate the patient on foot care. However, this patient is not in immediate danger, and can wait until the nurse finishes assessing the more critical patient.
Choice B reason: A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL is not the most critical patient to assess. Type 1 diabetes is a condition where the pancreas does not produce any insulin, a hormone that helps the cells use glucose for energy. Patients with type 1 diabetes need to take insulin injections or use an insulin pump to control their blood glucose level. A blood glucose reading of 230 mg/dL is above the normal range of 70 to 130 mg/dL before meals, and indicates hyperglycemia (high blood sugar). The nurse should check the patient's insulin dose, monitor the patient's symptoms, and provide education on blood glucose management. However, this patient is not in life-threatening condition, and can wait until the nurse attends to the more serious patient.
Choice C reason: A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output is the most important patient to assess. Hyperosmolar hyperglycemic syndrome (HHS) is a severe complication of diabetes that occurs when the blood glucose level is extremely high, usually above 600 mg/dL. HHS can cause dehydration, electrolyte imbalance, and coma. Dry oral mucosa and low urine output are signs of dehydration, which can lead to shock and organ failure. The nurse should assess the patient's vital signs, blood glucose level, fluid and electrolyte status, and neurological function. The nurse should also administer intravenous fluids, insulin, and electrolytes as prescribed by the health care provider. This patient is in a medical emergency, and needs immediate intervention.
Choice D reason: A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon is not the most acute patient to assess. Dawn phenomenon is a condition where the blood glucose level rises in the early morning, usually between 2:00 AM and 8:00 AM. This is due to the release of hormones that increase the blood glucose level, such as growth hormone, cortisol, and glucagon. The nurse should review the patient's blood glucose records, adjust the insulin dose or timing, and provide education on how to prevent or manage the dawn phenomenon. However, this patient is not in a critical situation, and can wait until the nurse evaluates the more unstable patient.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Burning pain and tingling in extremities are not symptoms of autonomic neuropathy, but of peripheral neuropathy. Peripheral neuropathy affects the sensory and motor nerves that innervate the skin, muscles, and joints. It can cause pain, numbness, weakness, and loss of sensation in the extremities. Autonomic neuropathy affects the nerves that control the involuntary functions of the body, such as digestion, blood pressure, heart rate, and sweating.
Choice B reason: Nausea and feeling of abdominal fullness are symptoms of autonomic neuropathy, specifically of gastroparesis. Gastroparesis is a condition where the stomach muscles are weakened or paralyzed, and cannot move food properly. It can cause delayed gastric emptying, nausea, vomiting, bloating, early satiety, and poor blood glucose control. Autonomic neuropathy can damage the vagus nerve, which regulates the stomach motility and secretion.
Choice C reason: Elevated blood pressure and delayed capillary refill are not symptoms of autonomic neuropathy, but of cardiovascular problems. Blood pressure is the force of blood against the walls of the arteries, and capillary refill is the time it takes for the color to return to the nail bed after pressing on it. Elevated blood pressure can indicate hypertension, which is a risk factor for heart disease and stroke. Delayed capillary refill can indicate poor blood circulation, which can be caused by atherosclerosis, peripheral artery disease, or shock. Autonomic neuropathy can affect the blood pressure and heart rate, but usually causes hypotension and tachycardia, not hypertension and delayed capillary refill.
Choice D reason: Increased thirst and excessive urination are not symptoms of autonomic neuropathy, but of diabetes mellitus. Diabetes mellitus is a condition where the body cannot produce or use insulin properly, and the blood glucose level becomes too high. Increased thirst and excessive urination are signs of hyperglycemia, which is a high blood glucose level. Hyperglycemia can cause dehydration, electrolyte imbalance, and ketoacidosis. Autonomic neuropathy can be a complication of diabetes mellitus, but it does not cause increased thirst and excessive urination.
Correct Answer is A
Explanation
Choice A reason: Metabolic acidosis is a condition where the blood pH is lower than normal, due to an excess of acids or a loss of bases in the body. Jo is most at risk of developing metabolic acidosis, because of the high blood glucose level. High blood glucose can cause diabetic ketoacidosis, a complication of Type 1 Diabetes, where the body breaks down fat for energy and produces ketones, which are acidic substances. Ketones can accumulate in the blood and lower the pH, causing symptoms such as nausea, vomiting, abdominal pain, fruity breath, and confusion.
Choice B reason: Metabolic alkalosis is a condition where the blood pH is higher than normal, due to an excess of bases or a loss of acids in the body. Jo is not likely to develop metabolic alkalosis, because of the high blood glucose level. Metabolic alkalosis can be caused by conditions such as vomiting, diuretic use, or excessive antacid intake, which can increase the bicarbonate level or decrease the chloride level in the blood. These conditions are not related to Jo's diabetes.
Choice C reason: Respiratory acidosis is a condition where the blood pH is lower than normal, due to an accumulation of carbon dioxide in the body. Jo is not prone to developing respiratory acidosis, because of the high blood glucose level. Respiratory acidosis can be caused by conditions that impair the lung function, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia, which can reduce the ventilation and increase the carbon dioxide level in the blood. These conditions are not related to Jo's diabetes.
Choice D reason: Respiratory alkalosis is a condition where the blood pH is higher than normal, due to a loss of carbon dioxide in the body. Jo is not susceptible to developing respiratory alkalosis, because of the high blood glucose level. Respiratory alkalosis can be caused by conditions that increase the breathing rate, such as anxiety, fever, or hyperventilation, which can reduce the carbon dioxide level in the blood. These conditions are not related to Jo's diabetes.
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