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CONCEPT 32: ASSESSMENT About Assessment 1. 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. Answer: 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. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Creating Learning Outcome: 1. Describe different types of assessments, indicating the proper use of each.
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TEST BANK: NURSING: A CONCEPT BASED APPROACH TO LEARNING, VOLUME2, NURSING, NURSINGTEST BANK
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