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.
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.
The Correct Answer is []
Potential Condition:
- B. Type 1 diabetes mellitus
The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.
Actions to Take:
- B. Teach the client about the signs of hyperglycemia.
- D. Assess the client’s feet for sensation.
Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.
Parameters to Monitor:
- B. Blood pressure
- D. Fingerstick blood glucose
Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not typically the symptom that should be prioritized. While discomfort can indicate an active ulcer, it does not necessarily signify a complication.
Choice B rationale
Hematemesis, or vomiting blood, is a serious symptom that could indicate a bleeding ulcer, which is a medical emergency. Therefore, this symptom should be prioritized.
Choice C rationale
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease. However, it is not typically the symptom that should be prioritized as it does not necessarily indicate a serious complication.
Choice D rationale
Constipation is not typically associated with peptic ulcer disease and therefore should not be prioritized.
Correct Answer is A
Explanation
Choice A rationale
Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.
Choice B rationale
Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.
Choice C rationale
Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
Choice D rationale
Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
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