The nurse is caring for a client who has diabetes mellitus and reports having a headache, nausea, is diaphoretic and then loses consciousness. Which of the following actions should the nurse take?

Assess the client for the need for compressions.

Perform a sternal rub to arouse the client.

Provide 15 g of a fast-acting carbohydrate.

Administer a prescribed injectable glucagon.

Answer and Explanation

The Correct Answer is D

A. This action is not appropriate unless the client is in cardiac arrest. The client is unconscious but not necessarily in need of compressions based on the symptoms described.
B. While the sternal rub can be used to assess for a response, it is not the best intervention in this situation. If the client is unconscious and showing signs of hypoglycemia, immediate treatment should focus on addressing the cause (low blood sugar) rather than trying to arouse the client.
C. While providing a fast-acting carbohydrate is appropriate for mild hypoglycemia, the client has lost consciousness, which indicates a more severe level of hypoglycemia. In this case, injectable glucagon is the preferred intervention to raise the client's blood sugar quickly.
D. The client’s symptoms (headache, nausea, diaphoresis, loss of consciousness) suggest hypoglycemia. When a client loses consciousness, injectable glucagon should be administered to rapidly raise blood sugar levels. If the client is conscious later, oral carbohydrates can be given, but in this case, injectable glucagon is the immediate priority.

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Correct Answer is C

Explanation

A. Dextrose is used to treat hypoglycemia (low blood sugar), and there is no indication from the vital signs provided that the client is hypoglycemic.
B. Acetaminophen is an antipyretic (fever reducer), but the priority is not to treat the fever immediately in this case. The client's blood pressure and heart rate need to be addressed first.
C. Propranolol is a beta-blocker that can help reduce both heart rate and blood pressure. The client has severe hypertension (200/110) and tachycardia (heart rate of 160), which may indicate a hypertensive crisis or severe adrenergic overactivity. Propranolol can help lower the heart rate and blood pressure quickly, which is crucial to avoid further cardiovascular complications.
D. Potassium iodide is used in cases of thyroid storm or exposure to radioactive iodine. It is not appropriate for this situation, as the symptoms do not indicate a thyroid emergency or radiation exposure.

A. Active rewarming may increase oxygen demands. B. Electric cords from heating pads can be a choking hazard. C. Heating pads could cause tissue burns. D. Warm blankets are more comforting for the client.

Correct Answer is C

Explanation

A. The statement active rewarming may increase oxygen demands is true for some conditions, like hypothermia, but it is not the primary reason to avoid heating pads for a client with myxedema. While rewarming can increase oxygen demands, the primary concern with heating pads is the risk of burns due to impaired thermoregulation in myxedema.
B. This is not relevant to the scenario. The concern with heating pads is not about choking hazards but about burns and safe rewarming.
C. In myxedema, the body’s ability to regulate temperature and respond to thermal stimuli is impaired due to severe hypothyroidism. This puts the client at a higher risk for burns if heating pads are used. Using warm blankets instead of heating pads ensures a safer, more gradual rewarming process.
D. While warm blankets may indeed be more comforting, the primary reason for using them instead of heating pads is to avoid the risk of burns due to impaired temperature regulation.

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The nurse is caring for a client who has diabetes mellitus and reports having a headache, nausea, is diaphoretic and then loses consciousness. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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