The nurse is reviewing the patient's record. Select to highlight the findings that demonstrate that the patient is improving.
1430: Nurses' Note: Urine output 50 mL/hr dark amber color. Continues to be lethargic.
1430: Vital Signs: Temp 100.4°F (37.8°C) HR 110 bpm: regular RR 24 breaths/min: rapid, deep SpO2 98% on room air BP 94/56 mm Hg
1430: Labs: Glucose 460 mg/dl
HR 110 bpm
regular RR 24 breaths/min
BP 94/56 mm Hg
Glucose 460 mg/dl
The Correct Answer is ["A","B","C","D"]
HR: 110 bpm; regular - The heart rate has decreased from 115 bpm and is now regular, suggesting improved cardiac rhythm stability.
RR: 24 breaths/min; rapid, deep - The respiratory rate has decreased from 26 breaths/min, indicating less rapid breathing.
BP: 94/56 mm Hg - While the blood pressure remains relatively low, there is a slight improvement compared to the previous reading.
Glucose 460 mg/dl - The glucose level has decreased from 525 mg/dL and 530 mg/dL in previous readings. While still elevated, this indicates some improvement in hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Medical nutrition therapy for diabetes involves creating a well-balanced, individualized meal plan that meets the patient's nutritional needs while helping to manage blood glucose levels. This approach can be healthy for the entire family and does not require separate meals or special foods. It promotes overall healthy eating habits that everyone can benefit from.
A. Low-carbohydrate diets may be considered for some patients but the emphasis of a diabetic diet is not necessarily on high-protein intake. Instead, the focus is on balanced meals that include appropriate amounts of carbohydrates, proteins, and fats.
B. People with diabetes do not require special foods; rather, they need to make healthier choices from the foods available. The emphasis is on a balanced diet that can include regular foods, with modifications to portion sizes and meal timing to manage blood glucose levels effectively.
D. It is not necessary to completely avoid sugars and fats; rather, the focus should be on moderating intake and choosing healthier options. For example, limiting added sugars and unhealthy fats (like trans fats and saturated fats) is important, but healthy fats (such as those from nuts, seeds, and avocados) can be part of a balanced diet.
Correct Answer is C
Explanation
C. Good control of blood glucose levels and blood pressure is essential in reducing the risk of diabetic retinopathy and its progression. Research has shown that maintaining tight glycemic control and managing hypertension can significantly decrease the likelihood and severity of retinopathy in patients with diabetes.
A. Laser surgery is a treatment option for certain complications of diabetic retinopathy, such as retinal hemorrhage or retinal detachment. However, it's essential to emphasize that prevention through good glycemic control and regular eye exams is key to reducing the risk of these complications, rather than relying solely on surgical interventions after they occur.
B. Cataracts are more common in individuals with diabetes and can be surgically corrected but this statement does not directly address the concern about retinopathy. Cataracts and retinopathy are separate ocular complications of diabetes, each requiring different management strategies.
D. Diabetes remains one of the leading causes of blindness in the United States, primarily due to its association with diabetic retinopathy. While advancements in diabetes management and eye care have helped reduce the incidence of blindness, it is still a significant concern for individuals with diabetes.
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