A nurse is caring for a client who is terminally ill. Which of the following findings should the nurse identify as an indication that palliative care should be recommended?

Rationale for Correct Choice

• Administer regular insulin 4 units subcutaneously x 1 dose: The client’s blood glucose is significantly elevated at 250 mg/dL and they are showing signs of hyperglycemia (polyuria, weight loss, nausea). Administering insulin addresses an immediate metabolic imbalance and helps prevent complications such as diabetic ketoacidosis.

Rationale for Incorrect Choices

• Apply dressing to the foot wound: Although the wound requires care, it is not the most urgent issue. Delaying insulin administration in a hyperglycemic client with systemic symptoms could increase the risk of metabolic crisis. Wound care can follow stabilization.
• Schedule an appointment with an ophthalmologist: While ophthalmologic evaluation is essential for clients with diabetes, this is a non-urgent referral and can be scheduled after acute needs like hyperglycemia and wound care are addressed.
• Consult an outpatient wound care specialist: Coordinating specialized wound care is important for infection control and healing, but it is not time-sensitive. The priority is addressing the elevated blood glucose level first to stabilize the client's condition.

Rationale for correct choices:

• Myocardial infarction: Elevated troponin levels are a specific biomarker for myocardial injury. The client’s Troponin T rose from 0.08 to 0.2 ng/mL, and Troponin I from 0.01 to 0.1 ng/mL, both exceeding normal limits, suggesting ongoing cardiac muscle damage consistent with a myocardial infarction.
• Troponin levels: Troponins are proteins released into the bloodstream when cardiac muscle is injured. A marked rise in both Troponin T and I over a short period indicates acute coronary syndrome progressing to myocardial infarction, especially in a client with chest pain unrelieved by nitroglycerin.

Rationale for incorrect choices:

• Bleeding: The client’s aPTT is 32 seconds and platelet count is 350,000/mm³, both within normal ranges. These do not suggest any coagulopathy or increased bleeding risk, especially prior to thrombolytic therapy.
• Pulmonary embolism: While shortness of breath and anxiety can be symptoms of a pulmonary embolism, the primary lab indicator—rising troponins—points toward cardiac injury. Additionally, pulmonary embolism is typically diagnosed with D-dimer, CT angiography, or V/Q scan, not troponin trends.
• Shortness of breath: Though concerning, shortness of breath is a nonspecific symptom and can occur in multiple conditions including angina, anxiety, and myocardial infarction. It is not the primary diagnostic indicator in this case and does not support a specific risk like the troponin trend does.
• aPTT levels: The client’s aPTT is 32 seconds, which is within the normal reference range of 30–40 seconds. This does not suggest impaired clotting and therefore does not indicate a bleeding risk at this time.