Recognizing & Analyzing Cues
A patient with type 1 diabetes is found diaphoretic, shaky, and confused with a blood glucose of 48 mg/dL.
This analysis of the cues is MOST accurate.
What is hypoglycemia?
This condition becomes your top suspicion when a teen with type 1 diabetes shows rapid deep breathing, fruity‑smelling breath, abdominal pain, and a blood glucose of 392 mg/dL
What is DKA?
When a client with long‑standing hypothyroidism becomes hypothermic, bradycardic, and obtunded, this med is the first nursing action needed to stabilize the condition.
What is IV levothyroxine?
When teaching a client starting basal‑bolus insulin therapy, this is the MOST important instruction to prevent severe hypoglycemia when exercising.
What is teaching the patient to eat a carbohydrate snack before exercise?
When triaging clinic patients with diabetes, this is the reason you evaluate this patient first: the one who presents with a blister on the plantar surface, redness spreading around it, and loss of protective sensation.
What is the patient is at risk for diabetic foot infection requiring immediate wound evaluation?
A postoperative neurosurgery client has urine output of 850 mL over 2 hours, serum sodium 152 mEq/L, and reports extreme thirst.
This cue is MOST important for the nurse to recognize as indicative of diabetes insipidus.
What is high urine output?
This condition outranks other possibilities—including stroke—when a diabetic client suddenly becomes confused, shaky, diaphoretic, and has a glucose of 54 mg/dL
What is hypoglycemia?
In a postoperative pituitary surgery patient who suddenly develops high urine output, low specific gravity, and rising serum sodium, this med is what the nurse should give first.
What is administering vasopressin or desmopressin?
When caring for a patient with SIADH, this teaching point is crucial to prevent worsening hyponatremia.
What is following a strict fluid restriction?
Among postoperative transsphenoidal hypophysectomy clients, this is the reason this patient takes priority: the one who suddenly develops a large amount of clear nasal drainage.
What is a suspected CSF leak?
A client with small‑cell lung cancer has serum sodium 124 mEq/L, serum osmolality 265 mOsm/kg (low), and urine output of only 300 mL over 8 hours.
This conclusion is MOST consistent with the cues.
What is SIADH?
Fatigue, weight loss, and hyperpigmentation (bronzing of the skin) push this disease to the top of your hypothesis list.
What is Addison's disease?
When a client with Addison’s disease arrives with severe hypotension, vomiting, and a history of missing steroid doses, this is the first nursing action that takes priority.
What is administering IV hydrocortisone?
When educating a patient newly prescribed levothyroxine, this instruction is essential because it determines whether the medication will absorb correctly.
What is teaching the patient to take levothyroxine on an empty stomach, 30–60 minutes before breakfast?
When caring for a patient admitted with suspected DKA, this assessment should be performed first because it indicates the severity of metabolic acidosis (other than labwork)
What is assessing for Kussmaul respirations?
A client with untreated hyperthyroidism presents with fever of 103.6°F (39.8°C), restlessness, hypertension, and new-onset confusion.
Based on these cues, the nurse suspects this complication.
What is thyroid storm?
You’d rank this condition highest on your list when a client presents with weight loss, palpitations, heat intolerance, anxiety, and a heart rate of 128/min.
What is hyperthyroidism?
A patient with hyperthyroidism suddenly develops a fever of 104°F, extreme tachycardia, and agitation. The priority action is this intervention to reduce the metabolic rate.
What is administration of a beta-blocker?
To reduce the risk of kidney stones, patients with hyperparathyroidism must understand this key lifestyle instruction.
What is teaching the patient to increase fluid intake to 2–3 liters per day?
You decide to evaluate this patient with hyperthyroidism first for this reason: the one who reports new-onset chest pain, shortness of breath, and a heart rate of 150/min.
What is this patient is demonstrating cardiac instability?
A client with Addison’s disease arrives to the ED with profound fatigue, blood pressure 82/48 mmHg, heart rate 118/min, and reports vomiting for the past 12 hours. The nurse notes the client has not taken prednisone for 2 days.
This cue is MOST significant for identifying the client’s priority problem of adrenal crisis.
What is BP of 82/48?
This life‑threatening complication jumps to the top of your differential when a client with hyperparathyroidism develops muscle weakness, constipation, and confusion.
What is hypercalcemia?
When a client with adrenal insufficiency shows a potassium level of 6.4 mEq/L and peaked T waves, this nursing action must be taken immediately to protect the heart.
What is administering calcium gluconate?
You emphasize this teaching priority because patients with Addison’s disease must prevent an adrenal crisis during illness, stress, or surgery.
What is teaching the patient to increase corticosteroid doses during times of stress ("stress dosing")?
You would see this postoperative thyroidectomy patient FIRST for this reason: the one who reports tingling around the mouth, has a positive Chvostek sign, and begins to experience muscle twitching.
What is the development of acute hypocalcemia?