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 C

Explanation

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.

A. Evaluate for evidence of incontinence. B. Observe for lacerations to the tongue. C. Document details of the seizure activity. D. Observe for prolonged periods of apnoea.

Correct Answer is D

Explanation

Choice A reason: Evaluating for evidence of incontinence is important for understanding the full scope of the seizure's impact on the client. However, it is not the first priority immediately after a seizure. Ensuring the client's airway and breathing status takes precedence.

Choice B reason: Observing for lacerations to the tongue is relevant as it can indicate the severity of the seizure and the potential for airway obstruction. However, the most critical intervention immediately after the seizure is to assess the client's breathing and ensure they are not experiencing prolonged apnoea.

Choice C reason: Documenting the details of the seizure activity is necessary for medical records and future treatment planning. While it is important, it is not the immediate priority. The nurse must first ensure the client's safety and physiological stability.

Choice D reason: Observing for prolonged periods of apnoea is the most urgent intervention. Apnoea, or a pause in breathing, can lead to hypoxia and other serious complications if not addressed immediately. Ensuring that the client is breathing properly is the top priority after a seizure.

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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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Correct Answer is C

Explanation

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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