The nurse notes a client with a prescription for glipizide is confused, diaphoretic, and tachycardic. What is the nurse’s priority assessment?
Blood glucose
Apical heart rate
INR level
Last bowel movement
The Correct Answer is A
Choice A reason: This choice is correct because blood glucose is the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Glipizide is a medicine that lowers blood sugar levels in the body. It can cause side effects such as anxiety, diarrhea, nausea, and low blood sugar. Low blood sugar (hypoglycemia) can cause confusion, sweating, fast heart rate, dizziness, hunger, and seizures. The nurse should check the client's blood glucose level and treat hypoglycemia as soon as possible.
Choice B reason: This choice is incorrect because apical heart rate is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Apical heart rate is the number of heartbeats per minute that can be heard at the apex of the heart. It can be affected by many factors, such as age, activity, stress, and medication. Tachycardia is a condition where the heart beats faster than normal, which can be a sign of low blood sugar, dehydration, infection, or heart problems. The nurse should check the apical heart rate after assessing and treating the blood glucose level.
Choice C reason: This choice is incorrect because INR level is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. INR stands for international normalized ratio, which is a measure of how long it takes the blood to clot. It is used to monitor the effect of anticoagulant drugs, such as warfarin, that prevent blood clots. Glipizide does not affect the INR level, and the client's symptoms are not related to bleeding or clotting. The nurse should check the INR level only if the client is taking anticoagulant drugs and has signs of bleeding or clotting.
Choice D reason: This choice is incorrect because the last bowel movement is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. The last bowel movement is the time and nature of the client's most recent defecation. It can be affected by many factors, such as diet, fluid intake, activity, medication, and bowel habits. Glipizide can cause diarrhea or constipation, which can affect the frequency and consistency of the bowel movement. The nurse should check the last bowel movement after assessing and treating the blood glucose level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Maintaining a healthy weight is important for lowering cholesterol levels and reducing the risk of cardiovascular disease. Obesity is associated with higher levels of LDL-cholesterol (the "bad" cholesterol) and lower levels of HDL-cholesterol (the "good" cholesterol). Losing weight can improve these ratios and lower blood pressure. ¹
Choice B reason: Avoiding cigarettes and other nicotine products is essential for preventing cardiovascular disease. Smoking damages the blood vessels and increases the risk of atherosclerosis, which is the buildup of plaque in the arteries. Smoking also lowers HDL-cholesterol and raises triglycerides, another type of fat in the blood. Quitting smoking can improve cholesterol levels and lower the risk of heart attack and stroke. ²
Choice C reason: Importance of regular exercise is another key factor for improving cholesterol levels and cardiovascular health. Exercise helps to lower LDL-cholesterol and raise HDL-cholesterol, as well as lower blood pressure and blood sugar. Exercise also strengthens the heart muscle and improves blood flow. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, or a combination of both. ³
Choice D reason: Positive stress management techniques are not directly related to cholesterol levels or statin medications, but they may have some benefits for cardiovascular health. Stress can increase blood pressure and heart rate, and may trigger unhealthy behaviors such as smoking, drinking, or overeating. Stress can also affect the immune system and inflammation, which may contribute to atherosclerosis. Learning to cope with stress in healthy ways, such as meditation, yoga, breathing exercises, or counseling, may help to lower the risk of cardiovascular disease. ⁴
Choice E reason: Healthy low fat diet options are an important part of lowering cholesterol levels and preventing cardiovascular disease. A diet that is high in saturated fat, trans fat, and cholesterol can raise LDL-cholesterol and lower HDL-cholesterol. A diet that is low in fat and high in fiber, fruits, vegetables, whole grains, and lean protein can lower LDL-cholesterol and raise HDL-cholesterol. Some foods, such as oats, nuts, soy, and fish, may have additional benefits for cholesterol levels. .
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Excessive urination is a sign of hyperglycemia because the body tries to flush out the excess glucose in the blood through the urine. This can also lead to dehydration and electrolyte imbalance.
Choice B reason: Excessive thirst is a sign of hyperglycemia because the body loses fluid and becomes dehydrated due to frequent urination. The thirst mechanism is activated to replenish the fluid loss.
Choice C reason: Diaphoresis is not a sign of hyperglycemia, but rather a sign of hypoglycemia (low blood sugar). Hypoglycemia can cause sweating, shakiness, anxiety, and confusion.
Choice D reason: Atrial fibrillation is not a sign of hyperglycemia, but rather a possible complication of hyperglycemia. Hyperglycemia can damage the blood vessels and the heart, increasing the risk of arrhythmias, such as atrial fibrillation.
Choice E reason: Excessive hunger is a sign of hyperglycemia because the body is unable to use the glucose in the blood for energy. The cells are starved of fuel, and the hunger signal is triggered to stimulate food intake..
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