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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?

A.

The client asks the AP to trim his broken toenail.

B.

The client reports urine that is dark yellow in color.

C.

The client reports dizziness when standing.

D.

The client refuses breakfast and requests to sleep.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Rationale:

A. Weight gain is typically associated with hypothyroidism; clients with hyperthyroidism often experience weight loss due to increased metabolism.

B. Frequent mood changes, including anxiety and irritability, are common in hyperthyroidism as a result of increased thyroid hormone levels affecting mood regulation.

C. Sensitivity to cold is associated with hypothyroidism; hyperthyroid clients usually have an increased sensitivity to heat.

D. Constipation is more characteristic of hypothyroidism; hyperthyroidism often causes increased bowel movements or diarrhea.

Correct Answer is C

Explanation

Rationale:

A. Clammy skin is associated with hypoglycemia, not diabetic ketoacidosis (DKA).

B. A rapid pulse can be present in DKA, but it is not a definitive indicator of the condition.

C. Polydipsia (excessive thirst) is a hallmark symptom of DKA, as the body tries to compensate for the severe dehydration caused by hyperglycemia and osmotic diuresis.

D. Confusion can occur in DKA, but it is usually a later sign when the condition becomes severe and metabolic acidosis worsens.

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