A client diagnosed with type 1 diabetes suddenly reports feeling weak, shaky, and dizzy. What should be the nurse's initial response?
Perform a blood sugar analysis.
Have the client drink a 4-ounce (120-mL) glass of orange juice.
Administer 1 ampule of 50% dextrose intravenously.
Administer 10 units of regular insulin subcutaneously.
The Correct Answer is B
A. Performing a blood sugar analysis is important, but in the case of sudden symptoms such as weakness, shakiness, and dizziness, it is crucial to act quickly to address the potential hypoglycemia without delay.
B. Having the client drink a 4-ounce glass of orange juice is the most appropriate initial response as it provides a quick source of glucose to alleviate symptoms of hypoglycemia, which is a common concern in clients with type 1 diabetes experiencing these symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an effective treatment for hypoglycemia but is typically reserved for severe cases where the patient is unable to consume oral glucose or is unconscious.
D. Administering 10 units of regular insulin subcutaneously would exacerbate the problem by lowering blood sugar further and is contraindicated in a patient experiencing hypoglycemic symptoms.
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Correct Answer is D
Explanation
A. Taking smaller doses of decongestants several times a day may be appropriate for some medications but does not address the risk of rebound congestion associated with prolonged use.
B. Expecting relief within a few days may not be realistic if the cold symptoms persist for 2 weeks, indicating a potential need for further evaluation.
C. OTC decongestants can be effective, and many patients find relief from symptoms without requiring a prescription.
D. Using decongestants for an extended period can lead to rebound congestion, where nasal passages become more congested once the medication is stopped, making this a crucial point for the nurse to communicate.
Correct Answer is ["A","B","C"]
Explanation
A. Auscultating bowel sounds is important because anticholinergic agents can decrease gastrointestinal motility, leading to reduced bowel sounds and potential constipation.
B. Monitoring urine output is crucial as anticholinergics can cause urinary retention, and assessing output helps identify any adverse effects on bladder function.
C. Monitoring heart rate is necessary since anticholinergic agents can cause tachycardia as a side effect, making it important to assess the client’s cardiovascular status.
D. Administering an antidiarrheal agent is not typically indicated, as anticholinergic agents often cause constipation rather than diarrhea.
E. Assessing deep tendon reflexes is not directly relevant to the effects of anticholinergic medications and is not typically prioritized in this context.