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The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}

Rationale:

  • Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
  • Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
  • Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
  • Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
  • Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
  • Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Hypernatremia: While mild hypernatremia can occur in severe dehydration, it is not a defining or consistent feature of type 1 diabetes. Electrolyte imbalances may vary depending on hydration and glucose levels.

B. Decreased serum osmolality: In type 1 diabetes, serum osmolality is typically increased due to hyperglycemia and the osmotic effect of glucose in the bloodstream, which draws water out of cells and into the vascular space. A decrease would be inconsistent with the expected metabolic state.

C. Ketones in the urine: Ketones in the urine are a hallmark of type 1 diabetes, especially when insulin is deficient. Without insulin, the body breaks down fat for energy, producing ketones as a byproduct, which can be detected in the urine during diabetic ketoacidosis.

D. Hypoglycemia: Hypoglycemia is a complication of diabetes management, often resulting from too much insulin or missed meals. It is not a presenting manifestation of newly diagnosed type 1 diabetes, which typically presents with hyperglycemia and related symptoms.

Correct Answer is C

Explanation

Rationale:
A. Increased pigmentation: Triamcinolone, a topical corticosteroid, is not known to cause increased skin pigmentation. In some cases, prolonged use can lead to hypopigmentation, especially in clients with darker skin tones.

B. Localized hair loss: Hair loss is not commonly associated with triamcinolone use. In fact, some corticosteroids may lead to localized hair growth due to their effects on the skin and follicles.

C. Thinning of the skin: Prolonged use of topical corticosteroids like triamcinolone can lead to skin atrophy. This manifests as thinning of the skin, increased fragility, and a higher risk of bruising or tearing with minimal trauma.

D. Increased sensitivity to the sun: Photosensitivity is not a typical side effect of triamcinolone. Sun protection is generally recommended for healthy skin care, but triamcinolone does not specifically increase sun sensitivity.

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