A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next?
Administer another half-cup of orange juice.
Administer a half-ampule of dextrose 50% intravenously.
Administer 10 units of regular insulin subcutaneously.
Administer 1 mg of glucagon intramuscularly.
The Correct Answer is A
Choice A rationale: The initial administration of orange juice, a simple carbohydrate, is the correct first step for mild hypoglycemia. Since the client's symptoms have not resolved within five minutes, it is appropriate to administer another dose of 15 grams of a simple carbohydrate to raise blood glucose levels. A half-cup of orange juice provides approximately 15 grams of carbohydrates.
Choice B rationale: Dextrose 50% IV is a hypertonic glucose solution administered for severe hypoglycemia when a client is unable to swallow or is unconscious. Since the client is awake and alert, they can safely ingest oral carbohydrates, and IV administration is not yet indicated.
Choice C rationale: Administering insulin, which lowers blood glucose, would worsen the client's hypoglycemic state and is contraindicated. The client's symptoms of shakiness, diaphoresis, and weakness are classic signs of hypoglycemia, indicating a need for glucose, not insulin.
Choice D rationale: Glucagon is a hormone that raises blood glucose by stimulating the liver to release stored glucose. It is typically used for severe hypoglycemia in unconscious clients or those who cannot receive oral glucose. Since the client is conscious, an oral carbohydrate is the preferred and safer option.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Polydipsia, polyphagia, polyuria, and glycosuria are hallmark clinical manifestations of uncontrolled diabetes mellitus. Polydipsia is excessive thirst due to hyperosmolarity and dehydration from polyuria. Polyphagia is increased hunger resulting from cellular starvation despite hyperglycemia. Polyuria is frequent urination caused by osmotic diuresis from glucose spilling into the renal tubules, and glycosuria is the presence of glucose in the urine.
Choice B rationale: While obesity and excessive sugar consumption are risk factors for developing type 2 diabetes, they are not direct clinical symptoms of the disease itself. They are associated with the metabolic syndrome that often precedes diabetes. The symptoms are the physiological consequences of insulin resistance or deficiency, leading to hyperglycemia.
Choice C rationale: While weight loss can occur in uncontrolled diabetes (due to osmotic diuresis and catabolism), nervousness and dysuria are not primary, classic symptoms. Dysuria (painful urination) is more indicative of a urinary tract infection, which can be a complication of diabetes, but not a core symptom. Nervousness is a symptom of hypoglycemia, not typically hyperglycemia.
Choice D rationale: A blood glucose level of 90 mg/100 mL is within the normal range (fasting blood glucose is 70–100 mg/dL). Therefore, this finding does not indicate diabetes mellitus. While albumin in the urine (microalbuminuria) is a sign of diabetic nephropathy, a long-term complication, it is not a direct, initial clinical symptom of the disease's onset.
Correct Answer is B
Explanation
Choice A rationale: Hyperglycemia results from a lack of insulin, leading to an inability of cells to uptake glucose. Glucagon functions as a hormone that stimulates the liver to convert stored glycogen into glucose, thereby raising blood glucose levels. Administering glucagon in an already hyperglycemic state would exacerbate the condition, potentially leading to a dangerous spike in blood sugar. It's used for low, not high, blood sugar.
Choice B rationale: Hypoglycemia, a dangerously low blood glucose level (typically below 70 mg/dL), can be caused by an overdose of insulin, which drives too much glucose into cells. Glucagon is a hormone that counteracts insulin's effects by stimulating glycogenolysis in the liver, releasing stored glucose into the bloodstream. This rapid increase in circulating glucose effectively treats the acute hypoglycemic episode, making it an essential emergency treatment.
Choice C rationale: Diabetic ketoacidosis (DKA) is a severe metabolic complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. It is caused by an absolute or relative lack of insulin. Administering glucagon would increase blood glucose levels even further, worsening the hyperglycemia, which is a primary component of DKA. Insulin and fluid replacement are the mainstays of treatment for DKA.
Choice D rationale: Hyperglycemia during 'sick days' is a common phenomenon in people with diabetes due to increased stress hormones like cortisol and epinephrine, which raise blood glucose. Administering glucagon would further elevate blood sugar, intensifying the existing hyperglycemia. Therefore, glucagon is contraindicated in this scenario, as it would worsen the metabolic state rather than improving it.
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