On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Obtain a glucometer reading.

Administer fruit juice.

Start an IV of dextrose.

Call the physician.

Answer and Explanation

The Correct Answer is A

choice A, Obtain a glucometer reading. The immediate action taken by the nurse is to obtain a glucometer reading to determine the client's blood glucose level. The client's symptoms are suggestive of hypoglycemia, a condition that can lead to coma and seizures if left untreated. Administering fruit juice or starting an IV of dextrose without first checking the client's blood glucose level can worsen the condition if the client's blood glucose is high. The physician should be notified if the client's blood glucose level is critically low or high and if the client's condition does not improve after treatment.
B.   Administering fruit juice can worsen the condition if the client's blood glucose is high.
C.   Starting an IV of dextrose can worsen the condition if the client's blood glucose is high.
D.   Calling the physician is not the immediate action, as the client needs urgent treatment.

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Correct Answer is B

Explanation

During a seizure, the nurse's priority is to ensure the client's safety by protecting them from injury. The nurse should loosen any tight clothing and move furniture or objects that may harm the client. The client should be turned onto their side to prevent aspiration, and suctioning the mouth is not indicated during the seizure. Restraints are not appropriate during a seizure, and inserting a tongue blade between the teeth can cause injury.

A. Bone radiographs. B. Glucose tolerance test in combination with a Growth hormone measurement. C. Growth hormone levels. D. A serum glucose level.

Correct Answer is B

Explanation

Glucose tolerance test in combination with a Growth hormone measurement. Acromegaly is a condition in which there is an excess of growth hormone (GH) production by the anterior pituitary gland, resulting in abnormal growth of bones and tissues in the body. The definitive diagnostic test for acromegaly involves a glucose tolerance test combined with a measurement of GH levels. During the test, the client will be given a dose of glucose, and the GH levels will be measured before and after the glucose is given. In acromegaly, the GH levels remain elevated even after glucose administration.

Choice A, bone radiographs, may show the enlarged bones associated with acromegaly, but it is not the definitive diagnostic test for the condition.

Choice C, growth hormone levels, is not specific enough for diagnosing acromegaly, as elevated GH levels can occur in other conditions as well.

Choice D, a serum glucose level, is not specific for acromegaly, as the glucose level may be normal in clients with the condition.

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On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

Correct Answer is B

Explanation

A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable for confirming acromegaly?

Correct Answer is B

Explanation

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