A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Place the client in a darkened room.

Obtain blood pressure reading.

Administer an oral analgesic.

Perform finger stick glucose.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

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Correct Answer is D

Explanation

Choice A reason: Applying drying agents on draining lesions every day is not recommended for clients with SLE. This approach can lead to excessive dryness and irritation of the skin, which can worsen the condition and cause additional discomfort. Moisturizing and protecting the skin are more appropriate measures.

Choice B reason: While avoiding contact with others can help prevent the spread of infections, it is not the most important aspect of skin care for SLE. SLE is an autoimmune condition, and managing skin care focuses more on protecting the skin from external triggers and minimizing inflammation.

Choice C reason: Tanning booths are not safe for clients with SLE. Exposure to UV light, whether from the sun or artificial sources, can exacerbate SLE symptoms and trigger flares. Therefore, it is important to avoid both direct sunlight and tanning booths.

Choice D reason: Using a very strong sunblock when out in the sun is crucial for clients with SLE. Sun exposure can worsen skin lesions and trigger flares, so it is essential to protect the skin with a high SPF sunblock, wear protective clothing, and seek shade whenever possible.

A. Offer support while explaining that acute illness can change the type of diabetes and its treatment. B. Advise the client that the insulin will be discontinued when the glycosylated haemoglobin A1C levels reflect good control. C. Remind the client that DM is a chronic progressive disease and lifelong insulin is usually needed. D. Explain that the insulin injections will probably be discontinued once stress and illness are resolved.

Correct Answer is D

Explanation

Choice A reason: While acute illness can affect diabetes management and treatment, it does not change the type of diabetes. This response might confuse the client more, as type 1 and type 2 diabetes are different conditions.

Choice B reason: Advising the client that insulin will be discontinued when glycosylated haemoglobin A1C levels reflect good control can be misleading. While good control might reduce the need for insulin, the primary reason for insulin use here is the stress and illness, not just A1C levels.

Choice C reason: Reminding the client that diabetes mellitus is a chronic progressive disease and lifelong insulin is usually needed is not accurate for type 2 diabetes. Many clients with type 2 diabetes can manage their condition without lifelong insulin therapy.

Choice D reason: Explaining that insulin injections will probably be discontinued once stress and illness are resolved is accurate and helps the client understand that the need for insulin is likely temporary due to the acute condition and stress on their body. This response provides clarity and reassurance without causing unnecessary concern.

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A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

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