A nurse is caring for a client who has diabetic ketoacidosis secondary to an infection. Which of the following prescriptions is the highest priority?
Obtain blood for culture and sensitivity.
Initiate IV infusion of regular insulin.
Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr.
Insert an indwelling urinary catheter.
The Correct Answer is B
A) Obtain blood for culture and sensitivity: While identifying the infection is important for treatment, it does not address the immediate metabolic crisis of diabetic ketoacidosis (DKA). This action is essential but secondary to stabilizing the client's current condition.
B) Initiate IV infusion of regular insulin: Administering insulin is critical in the management of DKA, as it helps to reduce blood glucose levels and halt the production of ketones, which are responsible for the acidosis. This intervention is vital for quickly correcting the metabolic derangement and stabilizing the patient.
C) Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr: While fluid replacement is important in the management of DKA to address dehydration and electrolyte imbalances, it is still not as immediately life-saving as starting insulin therapy. Fluid resuscitation typically follows the administration of insulin.
D) Insert an indwelling urinary catheter: This may be necessary for monitoring urine output and assessing kidney function, but it is not a priority intervention when addressing the acute complications of DKA. Insulin administration takes precedence in the immediate management plan.
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Correct Answer is D
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A)"Keeptheclient'sroomdarkatnighttopromotesleep.":Whilemaintainingadarkroomatnightcanhelpwithsleephygiene,individualswithAlzheimer'sdiseasebenefitfromconsistentroutinesandenvironmentsthathelpreduceconfusionandanxiety,notjustdarkness.
B)"Provideplentyofstimulationintheclient'sroom.":Whilesomestimulationisbeneficial,excessivestimulationcanoverwhelmsomeonewithAlzheimer'sdisease,leadingtoincreasedconfusionandagitation.
C)"Displayamonthlycalendarintheclient'sroom.":Amonthlycalendarmightbetoocomplexandoverwhelming.SimplercueslikedailyschedulesaremoreeffectiveforsomeonewithAlzheimer'sdisease.
D)"Providetheclientwithstructuredactivitiestofilltheirtime.":Structuredactivitiescanhelpmaintaintheclient'scognitivefunctionsandprovideasenseofroutine,whichisessentialforreducinganxietyandpromotingasenseofnormalcy.
Correct Answer is D
Explanation
A) 10: A score of 10 on the Glasgow Coma Scale (GCS) indicates a moderate level of impairment in consciousness. This score typically includes a range of responses in eye opening, verbal, and motor responses. Given the client's specific symptoms, this score does not accurately reflect their condition.
B) 13: A GCS score of 13 indicates mild impairment. This score usually requires the ability to open eyes spontaneously, follow commands, and exhibit appropriate verbal responses. Since the client is not opening their eyes and only making incomprehensible sounds, this score is not applicable.
C) 2: A score of 2 on the GCS would imply a severely compromised response, but it would be misleading since the client exhibits decerebrate posturing, which is a significant motor response indicating a level of neurological function. Thus, this score does not adequately represent the client's status.
D) 5: This is the correct score. The GCS includes a score of 1 for no eye opening, 2 for incomprehensible sounds, and 2 for decerebrate posturing. Adding these together (1 for eye opening + 2 for verbal + 2 for motor) results in a total of 5. This score reflects the severe impairment of consciousness and indicates the need for urgent medical evaluation and intervention.