The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.
What action should the nurse take first?
Obtain point-of-care glucose.
Assess urine for ketones.
Check blood pressure.
Review prior insulin prescriptions.
The Correct Answer is A
Choice A rationale
The first action the nurse should take when caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision is to obtain point-of-care glucose. These symptoms are indicative of hyperglycemia, and immediate blood glucose testing is necessary to confirm this and guide further treatment.
Choice B rationale
Assessing urine for ketones is important in managing diabetes, especially in cases of suspected diabetic ketoacidosis. However, this would not be the first action to take in this scenario.
Choice C rationale
Checking blood pressure is a standard part of any physical assessment, but it would not be the first action to take in this scenario.
Choice D rationale
Reviewing prior insulin prescriptions can provide valuable information about the patient’s management of their diabetes, but it would not be the first action to take in this scenario.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Flexing the knees is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. While it may provide some comfort, it does not provide the necessary support to the spine that is needed during movement.
Choice B rationale
Raising the hips is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This action could potentially cause strain or damage to the surgical site.
Choice C rationale
Crossing the arms and legs is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This action does not provide the necessary support to the spine during movement.
Choice D rationale
Performing a log roll is the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This technique involves the patient keeping their body in alignment while turning onto their side. It helps to maintain the integrity of the spinal fusion and prevent injury to the surgical site.
Correct Answer is B
Explanation
Choice A rationale
Sodium levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.
Choice B rationale
Hypoparathyroidism leads to abnormally low levels of parathyroid hormone, which results in low calcium levels in the blood. A carpal spasm when pressure is applied to the upper arm, also known as Trousseau’s sign, is a common symptom of hypocalcemia.
Choice C rationale
Potassium levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.
Choice D rationale
Chloride levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.
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