A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL).

A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours.

A client who has Graves' disease with a heart rate of 100/min and reports tremors.

A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.

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Correct Answer is B

Explanation

Choice A reason:
Advising to avoid exercise during flare-ups of fibromyalgia can be beneficial. During flare-ups, symptoms such as muscle pain and fatigue are heightened, and rest may be necessary. However, gentle exercises like stretching or water aerobics might still be recommended to maintain muscle flexibility and strength.

Choice B reason:
Establishing a regular sleep pattern is crucial for managing fibromyalgia. Sleep disturbances are common in fibromyalgia, and poor sleep can exacerbate pain and fatigue. Good sleep hygiene, including a consistent sleep schedule and a comfortable sleep environment, can help improve sleep quality and overall symptom management.

Choice C reason:
While regular exercise is important in managing fibromyalgia, jogging or running may not be suitable for all individuals, especially during periods between flare-ups. Low-impact exercises are generally recommended to reduce stress on the joints and muscles.

Choice D reason:
There is no specific recommendation to increase calcium intake as a self-care strategy for fibromyalgia. While maintaining a balanced diet is important, there is no direct link between calcium intake and fibromyalgia symptom management.

A. Bradycardia B. Moist mucous membranes C. Urine specific gravity 1.002

Correct Answer is C

Explanation

Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.

Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.

Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.

Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.

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A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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