A family member brings a client with type 1 diabetes mellitus to ...

[jake]

A family member brings a client with type 1 diabetes mellitus to the emergency department. The client is confused, has a heart rate of 100, respirations of 9, and a fruity smell to the breath. The initial action the nurse should take is to:
 
  1. Notify the physician.
   2. Call for the code team.
   3. Assess the blood sugar.
   4. Measure urine output.

Question 2

All of the following statements about pain are true EXCEPT
 
  a. pain is often misunderstood and misjudged
  b. the sensation of pain is the warning of potential tissue damage
  c. pain can be objectively measured by another individual
  d. pain may be absent in people with diabetic neuropathy

[thall411]

Answer to Question 1

3. Assess the blood sugar.

Rationale:
The client is showing signs of the beginning of a diabetic coma. The first step by the nurse would be to assess the client's blood sugar. The nurse would then notify the physician of the results. A code team is not necessary as the client is breathing and has a heart rate. Measuring urine output would be a component of an ongoing assessment.

Answer to Question 2

C
Because pain is subjective and cannot be objectively measured by another individual through a laboratory test or diagnostic data, pain is often misunderstood and misjudged. Pain can be a protective mechanism to prevent further tissue injury. The sensation of pain may be absent in people with diabetic neuropathy.