After change-of-shift report, which patient will the nurse assess first?
A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain
A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output
A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon
The Correct Answer is C
Choice A reason: A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain is not the most urgent patient to assess. Peripheral neuropathy is a complication of diabetes that affects the nerves, especially in the feet and legs. It can cause symptoms such as numbness, tingling, burning, or pain. The nurse should assess the patient's foot condition, provide pain relief, and educate the patient on foot care. However, this patient is not in immediate danger, and can wait until the nurse finishes assessing the more critical patient.
Choice B reason: A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL is not the most critical patient to assess. Type 1 diabetes is a condition where the pancreas does not produce any insulin, a hormone that helps the cells use glucose for energy. Patients with type 1 diabetes need to take insulin injections or use an insulin pump to control their blood glucose level. A blood glucose reading of 230 mg/dL is above the normal range of 70 to 130 mg/dL before meals, and indicates hyperglycemia (high blood sugar). The nurse should check the patient's insulin dose, monitor the patient's symptoms, and provide education on blood glucose management. However, this patient is not in life-threatening condition, and can wait until the nurse attends to the more serious patient.
Choice C reason: A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output is the most important patient to assess. Hyperosmolar hyperglycemic syndrome (HHS) is a severe complication of diabetes that occurs when the blood glucose level is extremely high, usually above 600 mg/dL. HHS can cause dehydration, electrolyte imbalance, and coma. Dry oral mucosa and low urine output are signs of dehydration, which can lead to shock and organ failure. The nurse should assess the patient's vital signs, blood glucose level, fluid and electrolyte status, and neurological function. The nurse should also administer intravenous fluids, insulin, and electrolytes as prescribed by the health care provider. This patient is in a medical emergency, and needs immediate intervention.
Choice D reason: A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon is not the most acute patient to assess. Dawn phenomenon is a condition where the blood glucose level rises in the early morning, usually between 2:00 AM and 8:00 AM. This is due to the release of hormones that increase the blood glucose level, such as growth hormone, cortisol, and glucagon. The nurse should review the patient's blood glucose records, adjust the insulin dose or timing, and provide education on how to prevent or manage the dawn phenomenon. However, this patient is not in a critical situation, and can wait until the nurse evaluates the more unstable patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is false. Acetaminophen (Tylenol) is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as acetaminophen is a mild analgesic that works by inhibiting the synthesis of prostaglandins, which are involved in inflammation and pain. Acetaminophen is not very effective for chronic, burning leg pain, which is likely caused by diabetic neuropathy, a nerve damage condition that affects the sensation and function of the legs.
Choice B reason: This statement is true. Gabapentin (Neurontin) is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as gabapentin is an anticonvulsant that works by modulating the activity of calcium channels, which are involved in transmitting pain signals from the nerves to the brain. Gabapentin is effective for chronic, burning leg pain, as it can reduce the intensity and frequency of neuropathic pain.
Choice C reason: This statement is false. Hydrocodone-Acetaminophen (Norco) is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as hydrocodone-acetaminophen is a combination of an opioid analgesic and a mild analgesic that works by binding to opioid receptors in the brain and spinal cord, and by inhibiting the synthesis of prostaglandins, respectively. Hydrocodone-acetaminophen is not very effective for chronic, burning leg pain, as it can cause tolerance, dependence, and addiction, and can also interact with oxycodone, which the patient is already taking.
Choice D reason: This statement is false. Aspirin is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the synthesis of prostaglandins, which are involved in inflammation and pain. Aspirin is not very effective for chronic, burning leg pain, as it can cause gastrointestinal bleeding, ulcers, and kidney damage, and can also interact with other medications that the patient may be taking, such as anticoagulants or antiplatelets.
Correct Answer is ["A","E","F"]
Explanation
Choice A reason: This statement is true. Distended neck veins are a sign of fluid volume overload, as they indicate increased central venous pressure and right-sided heart failure.
Choice B reason: This statement is false. Hypotension is a sign of fluid volume deficit, not fluid volume overload. Hypotension occurs when the blood pressure is too low to perfuse the vital organs.
Choice C reason: This statement is false. Increased serum osmolality is a sign of fluid volume deficit, not fluid volume overload. Increased serum osmolality occurs when the blood concentration of solutes, such as sodium and glucose, is too high due to fluid loss.
Choice D reason: This statement is false. Dry oral mucosa is a sign of fluid volume deficit, not fluid volume overload. Dry oral mucosa occurs when the oral cavity is dehydrated due to fluid loss.
Choice E reason: This statement is true. Decreased urine specific gravity is a sign of fluid volume overload, as it indicates diluted urine and impaired kidney function.
Choice F reason: This statement is true. Weight gain is a sign of fluid volume overload, as it indicates fluid retention and edema.
Choice G reason: This statement is false. Sunken anterior fontanelle is a sign of fluid volume deficit, not fluid volume overload. Sunken anterior fontanelle occurs when the soft spot on the baby's head is depressed due to fluid loss.
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