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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Foot inspection is not an annual/yearly screening, but a daily self-care practice for people with diabetes. Foot inspection involves checking the feet for any signs of injury, infection, or ulceration, such as cuts, blisters, redness, swelling, or drainage. Foot inspection can help prevent or detect foot problems, such as neuropathy, ischemia, or infection, which can lead to amputation if left untreated. The nurse should teach Jo how to inspect his feet every day, and how to care for his feet, such as washing, drying, moisturizing, trimming nails, and wearing proper footwear.
Choice B reason: Serum creatinine (Cr) is an annual/yearly screening for people with diabetes. Serum creatinine is a blood test that measures the level of creatinine, a waste product that is filtered by the kidneys. Serum creatinine can indicate the kidney function, and detect kidney damage or disease, which is a common complication of diabetes. The nurse should explain to Jo that he needs to have his serum creatinine checked every year, and that he should keep his blood glucose and blood pressure under control, as these are the main risk factors for kidney problems.
Choice C reason: Chest X-ray is not an annual/yearly screening for people with diabetes, unless they have symptoms or risk factors for lung diseases, such as tuberculosis, pneumonia, or cancer. Chest X-ray is an imaging test that uses X-rays to produce pictures of the lungs and the chest cavity. Chest X-ray can help diagnose or monitor lung conditions, such as infections, inflammations, or tumors. The nurse should ask Jo about his history of smoking, exposure to environmental pollutants, or respiratory symptoms, such as cough, shortness of breath, or chest pain, and refer him to a doctor if he needs a chest X-ray.
Choice D reason: White blood cell count (WBC) is not an annual/yearly screening for people with diabetes, unless they have signs or risk factors for infections, such as fever, wounds, or immunosuppression. White blood cell count is a blood test that measures the number and types of white blood cells, which are the cells that fight infections and inflammation. White blood cell count can help diagnose or monitor infections, such as bacterial, viral, or fungal infections, or immune disorders, such as allergies, autoimmune diseases, or cancers. The nurse should assess Jo for any signs of infection, such as fever, chills, malaise, or pus, and advise him to seek medical attention if he has any.
Correct Answer is A
Explanation
Choice A reason: I will need to take medication by mouth until my blood sugar is within normal limits again is an incorrect statement that indicates the need for further teaching. Type 1 diabetes mellitus (DM) 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 DM need to take insulin injections or use an insulin pump for life to replace the missing hormone. Oral medications for diabetes are not effective for type 1 DM, as they work by stimulating the pancreas to produce more insulin or by increasing the sensitivity of the cells to insulin.
Choice B reason: If I get the flu, the dose of my insulin may need to be altered to control my blood glucose is a correct statement that shows understanding of the disease process. Illnesses such as the flu can increase the blood glucose level, as the body releases hormones that counteract the effects of insulin. Patients with type 1 DM may need to adjust their insulin dose, monitor their blood glucose more frequently, and check for ketones in their urine or blood when they are sick. Ketones are acidic substances that are produced when the body breaks down fat for energy, and can lead to a serious complication called diabetic ketoacidosis.
Choice C reason: I will monitor my blood glucose to help determine whether my medication is working as anticipated is another correct statement that demonstrates knowledge of the disease management. Blood glucose monitoring is an essential part of diabetes care, as it helps the patients and the health care providers to evaluate the effectiveness of the insulin therapy, the diet, and the exercise plan. Blood glucose monitoring also helps to prevent or detect hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), and to adjust the insulin dose accordingly.
Choice D reason: The things that I eat may impact the dose of my medication used to control my blood glucose is also a correct statement that reflects awareness of the disease implications. The amount and type of carbohydrates that the patients eat can affect their blood glucose level, as carbohydrates are the main source of glucose in the diet. Patients with type 1 DM need to balance their insulin dose with their carbohydrate intake, and follow a consistent and healthy eating pattern. They may also use carbohydrate counting, a method of estimating the grams of carbohydrates in the foods they eat, to help them plan their meals and snacks.
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