A nurse is caring for a client who is being admitted to t

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A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.

Exhibits


Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.

Actions to Take:

Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.

Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.

Parameters to Monitor:

Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.

Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.

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Correct Answer is C

Explanation

A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.

B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.

C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.

D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.

A. Vital signs B. Weight C. Blood glucose level D. Presence of bruit and thrill E. Lung sounds F. AV fistula site assessment

Correct Answer is ["B","E","F"]

Explanation

A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.

B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.

C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.

D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.

E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.

F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.

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A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?

Correct Answer is C

Explanation

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Correct Answer is ["B","E","F"]

Explanation

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