A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?
The client refuses breakfast and requests to sleep.
The client asks the AP to trim his broken toenail.
The client reports urine that is dark yellow in color.
The client reports dizziness when standing.
The Correct Answer is A
Choice A rationale:
Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin. Insulin is a hormone that helps the body to use glucose for energy. Glucose is a sugar that comes, in large part, from foods we eat. Insulin allows glucose to enter cells in the body. Therefore, if a client with type 1 diabetes refuses breakfast and requests to sleep, it could lead to hypoglycemia, a condition characterized by abnormally low blood glucose levels. Hypoglycemia can cause symptoms such as weakness, sweating, confusion, and in severe cases, unconsciousness or seizures. It is a medical emergency and should be reported immediately.
Choice B rationale:
Trimming a toenail may seem like a simple task, but for a person with diabetes, it can lead to serious complications. Diabetes can cause nerve damage that leads to numbness in the feet, making it difficult for a person to feel a cut, blister, or sore. These injuries can become infected and lead to serious complications, such as the need for amputation. However, this situation is not as immediately life-threatening as hypoglycemia and does not need to be reported immediately.
Choice C rationale:
Dark yellow urine can be a sign of dehydration, which can be a concern for individuals with diabetes. However, it can also be a result of less serious causes such as certain medications, foods, or simply not drinking enough fluids. While it’s important for the AP to encourage the client to drink more fluids, this situation is not as immediately life-threatening as hypoglycemia.
Choice D rationale:
Dizziness when standing, also known as orthostatic hypotension, can be a side effect of some medications used to treat diabetes. It can also be a symptom of dehydration or other conditions. While it’s important for the AP to monitor the client’s symptoms and report any changes, this situation is not as immediately life-threatening as hypoglycemia
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hypoglycemia, also known as low blood sugar, is a condition where blood sugar levels fall below the standard range. It is often related to diabetes treatment. When blood glucose levels are too low, individuals may experience symptoms such as shakiness, which is why the statement “I will feel shaky” indicates an understanding of the manifestations of hypoglycemia.
Choice B rationale:
The statement “My skin will be warm and moist” does not accurately represent the symptoms of hypoglycemia. While sweating can be a symptom of hypoglycemia, it does not necessarily mean that the skin will feel warm and moist. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Choice C rationale:
The statement “I will be more thirsty than usual” is more commonly associated with hyperglycemia, or high blood sugar, rather than hypoglycemia. Thirst is not typically a symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Choice D rationale:
The statement “My appetite will be decreased” is not a typical symptom of hypoglycemia. In fact, hunger is a common symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Correct Answer is C
Explanation
Choice A rationale:
The client stating, “I haven’t had anything to eat or drink since last night” is not a cause for concern. This is because patients are often advised to fast before undergoing certain medical procedures or tests, including an intravenous pyelogram (IVP).
Fasting helps to ensure that the test results are accurate and not influenced by recent food or drink consumption.
Choice B rationale:
The client expressing that “The last time I voided it was painful” could be related to their recurrent kidney stones. Kidney stones can cause discomfort or pain during urination. However, this statement does not necessarily require additional data collection in the context of an IVP. The pain could be a symptom of the kidney stones rather than a contraindication for the IVP1.
Choice C rationale:
The statement “I took my metformin before breakfast” is of concern. Metformin is a medication used to treat type 2 diabetes. It is important for the nurse to collect additional data about this statement because metformin can potentially interact with the iodine-based contrast dye used in an IVP. This interaction can increase the risk of lactic acidosis, a serious and potentially lifethreatening condition. Therefore, patients are often advised to stop taking metformin before and for a couple of days after having an IVP12. Choice D rationale:
The client mentioning, “I took a laxative yesterday” is not necessarily alarming. Laxatives are often used before an IVP to clear the bowels, which helps to ensure clear images during the procedure. Therefore, this statement does not require additional data collection in the context of an IVP1.
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