A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.
Select the 3 findings that require immediate follow-up.
Glucose at 1130
Client report of shakiness
Temperature
Heart rate
SPO2
HbA1c
Correct Answer : A,B,D
A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bradykinesia, hand tremors, and memory loss are more characteristic of Parkinson's disease, not multiple sclerosis.
B. Ascending paralysis beginning in the lower extremities and dysphagia are typical of Guillain-Barré syndrome, not multiple sclerosis. MS does not usually present with paralysis but rather with muscle weakness and sensory disturbances.
C. Early signs of multiple sclerosis often include areas of numbness, weakness in the legs, and visual problems such as optic neuritis. These symptoms result from demyelination and nerve damage in the central nervous system.
D. Choreiform movements and loss of facial expression are associated with Huntington's disease, not multiple sclerosis.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}
Explanation
Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.
Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.
Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.
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