An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate?
States her feet are constantly cold along with feeling numb
Consecutive evening serum glucose greater than 260 mg/dL
A wound on the ankle that starts to drain and becomes painful
Reports nausea in the morning but still able to eat breakfast
The Correct Answer is B
The correct answer and explanation is:
b) Consecutive evening serum glucose greater than 260 mg/dL.
This is the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Consecutive evening serum glucose greater than 260 mg/dL indicates hyperglycemia, which means that the client's blood sugar is too high and not well controlled by the insulin dose.
The PN should report this finding to the healthcare provider and expect a possible adjustment in the insulin regimen.
a) States her feet are constantly cold along with feeling numb.
This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus.
States her feet are constantly cold along with feeling numb may indicate peripheral neuropathy, which is a complication of diabetes that affects the nerves in the feet and legs. It is caused by chronic high blood sugar levels over time, not by a single dose of insulin.
c) A wound on the ankle that starts to drain and becomes painful.
This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. A wound on the ankle that starts to drain and becomes painful may indicate an infection, which is a risk factor for diabetic clients due to impaired wound healing and immune function. It is not directly related to the insulin dose, although it may affect the blood sugar levels and require more insulin.
d) Reports nausea in the morning but still able to eat breakfast.
This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Reports nausea in the morning but still able to eat breakfast may indicate morning sickness, which is a common symptom of pregnancy. It is not related to the insulin dose, although it may affect the blood sugar levels and require more frequent monitoring and adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential to cause extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Correct Answer is A
Explanation
Choice A rationale:
Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.
Choice B rationale:
Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.
Choice C rationale:
Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.
Choice D rationale:
Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.
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