The nurse is caring for a female client with type 2 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice.
I.V. bolus of dextrose 50%.
I.M. or subcutaneous glucagon.
10 U of fast-acting insulin
The Correct Answer is C
A. 15 to 20 g of a fast-acting carbohydrate such as orange juice:
This is a standard and initial treatment for hypoglycemia. Fast-acting carbohydrates, like orange juice or glucose tablets, can quickly raise blood sugar levels. However, in the scenario described, the client is still conscious, and glucagon may be a more appropriate choice.
B. I.V. bolus of dextrose 50%:
Intravenous (IV) dextrose is a more aggressive intervention and is typically reserved for severe cases of hypoglycemia or for unconscious patients. It is not the first-line treatment for conscious patients.
C. I.M. or subcutaneous glucagon:
Glucagon is a hormone that raises blood sugar levels by promoting the conversion of stored glycogen in the liver to glucose. It is administered either intramuscularly (I.M.) or subcutaneously. In a conscious patient with hypoglycemia who cannot take oral carbohydrates, glucagon can be an effective and rapid way to raise blood sugar levels.
D. 10 U of fast-acting insulin:
Administering more insulin in a situation of hypoglycemia would worsen the condition. The goal in hypoglycemia is to raise blood sugar, and giving more insulin would have the opposite effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Development of a buffalo hump and moon face:
This is associated with Cushing's syndrome, a disorder characterized by prolonged exposure to high levels of cortisol.
B. Central obesity and purple striations:
Also indicative of Cushing's syndrome, where excess cortisol can lead to the accumulation of fat in the abdominal area (central obesity) and the development of purple stretch marks (striae).
C. Sudden weight loss without dieting:
This is more characteristic of hyperthyroidism, where the thyroid gland is overactive, leading to increased metabolism and unintended weight loss.
D. Positive Trousseau's sign when checking the client's blood pressure:
Trousseau's sign is associated with hypocalcemia and is seen in conditions affecting the parathyroid gland rather than the thyroid. It involves carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.
Correct Answer is B
Explanation
A. Urinalysis shows trace protein:
Explanation: While trace protein in the urine is generally better than higher levels, it doesn't provide a specific measure of blood glucose control. Protein in the urine can be an early sign of kidney damage in diabetes, but it doesn't directly indicate blood glucose control.
B. Hemoglobin A1C of 5.6%:
Explanation: Hemoglobin A1C (HbA1C) is a long-term indicator of blood glucose control. An HbA1C level of 5.6% is within the target range for individuals with diabetes and suggests good control of blood glucose over the past 2-3 months.
C. Fasting blood glucose of 110 mg/dL:
Explanation: Fasting blood glucose gives a snapshot of blood glucose at a specific moment. While 110 mg/dL is a fairly normal fasting level, it doesn't provide information about long-term control. A single fasting glucose measurement may not reflect overall glucose management.
D. Urine ketones are negative:
Explanation: Negative urine ketones indicate that the body is not currently using fat for energy. While this is a good sign in the moment, it doesn't give information about overall blood glucose control over time. Urine ketones can fluctuate based on various factors, including diet and activity level.
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