A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?
The client asks the AP to trim his broken toenail.
The client reports urine that is dark yellow in color.
The client reports dizziness when standing.
The client refuses breakfast and requests to sleep.
The Correct Answer is D
Rationale:
A. Toenail trimming should be performed by a professional to prevent injury, but it does not require immediate reporting.
B. Dark yellow urine can indicate dehydration, but it is not an urgent concern in this context.
C. Dizziness when standing is a concern, but it does not take priority over the refusal of breakfast, which may lead to hypoglycemia.
D. A refusal to eat can lead to hypoglycemia in clients with type 1 diabetes, and this situation should be reported immediately to prevent a dangerous drop in blood glucose levels.
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Correct Answer is A
Explanation
Rationale:
A. Checking the client's blood glucose level is the priority action to assess the current state of the client's blood glucose after administering the incorrect dose of insulin, which is essential for determining if further intervention is needed.
B. While giving carbohydrates might be necessary if the blood glucose level is low, checking the blood glucose first will provide the necessary information for the next steps.
C. Notifying the nurse manager is important, but it should not take precedence over assessing the client's current condition.
D. Completing an incident report is a required administrative task, but the immediate concern is the client's safety and well-being, which necessitates checking their blood glucose first.
Correct Answer is D
Explanation
Rationale:
A. Abruptly withdrawing corticosteroid therapy can lead to adrenal insufficiency, not Cushing syndrome.
B. Poorly functioning adrenal glands cause Addison’s disease, not Cushing syndrome.
C. Lacking ACTH leads to secondary adrenal insufficiency, not Cushing syndrome.
D. Taking corticosteroids for many years can result in exogenous Cushing syndrome due to prolonged exposure to high cortisol levels, which mimic the effects of endogenous Cushing syndrome.