Question

The client with diabetes presents to the emergency department with pupils dilated. Which action by the nurse indicates understanding of the client's presenting symptom? A. The nurse checks the client's Hgb A1C. B. The nurse begins an IV of normal saline. C. The nurse applies oxygen via mask at 3 liter/minute. D. The nurse gives the client \(240 \mathrm{ml}\) of apple juice.

Short answer

A. Check the client's Hgb A1C B. Begin an IV of normal saline C. Apply oxygen via mask at 3 liters/minute D. Give the client 240 ml of apple juice Answer: D. Give the client 240 ml of apple juice. Justification: Dilated pupils in a client with diabetes can be a symptom of hypoglycemia (low blood sugar). Apple juice contains sugar and can help to quickly raise blood sugar levels in a hypoglycemic patient. Therefore, giving the client apple juice is the most appropriate action by the nurse in this case as it directly addresses the client's presenting symptom.

Step-by-step solution

Analyze the question

First, let's identify the key information given in the question: - The client has diabetes. - The client has dilated pupils. The question asks which nursing action indicates understanding of the client's presenting symptom. We are given four possible nursing actions (A, B, C, and D) and our goal is to figure out which one is the best response.

Eliminate the incorrect actions

We'll go through each of the nursing actions and eliminate the ones that are not related to the client's presenting symptom of dilated pupils. A. The nurse checks the client's Hgb A1C. This action tests the client's blood sugar levels over the past 2-3 months but does not directly address the client's presenting symptom of dilated pupils. Eliminate A. B. The nurse begins an IV of normal saline. This action is typically done to rehydrate a patient or to maintain fluid balance. While it may be useful in some diabetes cases, it is not the most appropriate action to address dilated pupils specifically. Eliminate B. C. The nurse applies oxygen via mask at 3 liter/minute. This action is taken to provide the client with supplemental oxygen but does not specifically address the symptom of dilated pupils in a diabetic patient. Eliminate C.

Identify the correct action

After eliminating the incorrect actions, we are left with one answer choice: D. The nurse gives the client \(240 \mathrm{ml}\) of apple juice.

Justify the correct action

Dilated pupils in a client with diabetes can be a symptom of hypoglycemia (low blood sugar). Apple juice contains sugar and can help to quickly raise blood sugar levels in a hypoglycemic patient. Therefore, giving the client apple juice is the most appropriate action by the nurse in this case as it directly addresses the client's presenting symptom. The correct answer is D.