A nurse in an emergency department is caring for an older adult client who has diabetes mellitus and is in a hyperglycemic-hyperosmolar state. Which of the following actions should the nurse take first?

Evaluate the client's understanding of diabetes management.

Administer potassium supplements.

Initiate a continuous infusion of 0.9% sodium chloride.

Chek for improvements in the client's level of consciousness.

Answer and Explanation

The Correct Answer is C

A) Evaluate the client's understanding of diabetes management: While it is important to assess the client’s understanding of diabetes management to prevent future hyperglycemic episodes, this is not the immediate priority. The client's current hyperglycemic-hyperosmolar state needs urgent intervention to stabilize their condition before educational measures can be effective.

B) Administer potassium supplements: Potassium supplementation may be necessary, especially if the client is hypokalemic, but it is not the first action. Electrolyte levels should be monitored and corrected as part of the treatment, but the initial priority is to address the severe dehydration and hyperglycemia.

C) Initiate a continuous infusion of 0.9% sodium chloride: This is the most critical first step. Clients in a hyperglycemic-hyperosmolar state are typically severely dehydrated due to osmotic diuresis. Initiating a continuous infusion of isotonic saline helps to restore intravascular volume, improve perfusion, and stabilize hemodynamics, which is essential before addressing other issues.

D) Check for improvements in the client's level of consciousness: Monitoring the client's level of consciousness is important as it provides information about their neurological status and response to treatment. However, this is a subsequent action after initiating fluid resuscitation, which directly addresses the immediate life-threatening aspects of the hyperglycemic-hyperosmolar state.

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Correct Answer is C

Explanation

A) Weight gain: Weight gain is more commonly associated with right-sided heart failure due to fluid retention and peripheral edema. While left-sided heart failure can lead to overall heart failure, causing weight gain, it is not as specific as breathlessness for left-sided failure.

B) Warm extremities after walking: Warm extremities are generally a sign of good circulation. In clients with left-sided heart failure, reduced cardiac output often leads to poor peripheral circulation, which would more likely cause cool extremities.

C) Breathlessness when carrying an object: Left-sided heart failure leads to decreased cardiac output and pulmonary congestion. As a result, clients often experience breathlessness or dyspnea, especially during physical activities, because the heart cannot efficiently pump blood, leading to fluid buildup in the lungs.

D) Increased urinary output during the day: Left-sided heart failure usually causes decreased renal perfusion, leading to reduced urinary output during the day. Clients might experience nocturia (increased nighttime urination) due to fluid reabsorption when lying down, but increased daytime output is not typical.

A. Stroke B. Benign prostatic hyperplasia C. Meniere’s disease D. Hemophilia

Correct Answer is A

Explanation

A) Stroke:
Hyperlipidemia and type 2 diabetes mellitus both contribute significantly to the development of atherosclerosis, which can lead to stroke. High levels of lipids in the blood can cause plaque buildup in the arteries, and diabetes can damage blood vessels and increase the likelihood of clots forming.

B) Benign prostatic hyperplasia:
While benign prostatic hyperplasia is a common condition in older men, it is not directly related to hyperlipidemia or diabetes. It is more related to age and hormonal changes rather than metabolic or vascular conditions.

C) Meniere’s disease:
Meniere's disease is a disorder of the inner ear that leads to vertigo, tinnitus, and hearing loss. It is not associated with hyperlipidemia or diabetes. The primary risk factors are genetic predisposition and abnormalities in the ear's fluid dynamics.

D) Hemophilia:
Hemophilia is a genetic disorder that affects the blood's ability to clot. It is inherited and not influenced by lifestyle-related conditions such as hyperlipidemia or diabetes. The risk factors for hemophilia are primarily genetic, with no direct link to metabolic conditions.

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A nurse in an emergency department is caring for an older adult client who has diabetes mellitus and is in a hyperglycemic-hyperosmolar state. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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