NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
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NU473 Week 3 HESI Case Study Evolve Elsevier: Suicide, A Sentinel Event - 28 questions
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NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
NU473 Week 3 HESI Case Study Evolve Elsevier: Suicide, A
Sentinel Event - 28 questions
Activities to Question Regarding Client with Type II Diabetes Mellitus
The nurse should question the following activities related to the client’s diabetes management:
1. Client’s frequency for checkin...
NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
NU473 Week 3 HESI Case Study Evolve Elsevier: Suic
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NU473 Week 3 HESI Case Study Evolve Elsevier: Suicide, A
Sentinel Event - 28 questions
Activities to Question Regarding Client with Type II Diabetes Mellitus
The nurse should question the following activities related to the client’s diabetes management:
1. Client’s frequency for checking blood glucose.
- Rationale: Regular monitoring of blood glucose is crucial for managing diabetes, preventing
complications, and guiding treatment decisions.
2. Quantity of Ensure taken per day.
- Rationale: It's essential to assess caloric and nutritional intake, especially for a client with diabetes, as
Ensure can be high in carbohydrates, which could affect blood glucose levels.
3. Reason for lack of appetite.
- Rationale: Investigating a lack of appetite is important, as inadequate carbohydrate intake can lead to
hypoglycemia, especially if the client is on insulin.
4. Amount of water and other fluids taken daily.
- Rationale: Fluid intake is crucial for diabetes management to prevent dehydration, particularly when
glucose levels are high.
5. Last blood glucose result obtained by client.
- Rationale: Understanding the last known blood glucose reading helps to monitor the effectiveness of
the diabetes management plan and make necessary adjustments.
### Risk Factors for Major Depression
Given the client’s background, the nurse identifies the most significant risk for major depression:
- Becoming widowed within the past year.
, - Rationale: The loss of a spouse can significantly impact mental health, leading to increased risk for
depression due to feelings of loneliness and loss. Older adults are particularly vulnerable during this
transition.
### Physical Assessment Insights
From the provided assessment data, here are some important observations and potential nursing
concerns:
- Respiratory Status:
- Shallow respirations, nasal flaring, intercostal retractions, and productive cough indicate respiratory
distress or exacerbation of a chronic respiratory condition, such as COPD.
- Oxygen saturation of 88% on room air suggests hypoxemia; the nurse should intervene to administer
oxygen and assess the need for bronchodilator therapy.
- Cardiovascular Findings:
- Elevated heart rate (110 beats/min) may indicate stress, fever, or compensation for hypoxemia.
- Blood pressure of 150/90 mmHg may reflect increased work of breathing or anxiety.
- Skin Integrity:
- Stage II decubitus ulcer with a Braden score of 14 indicates a moderate risk for pressure ulcer
development; nursing interventions should include regular repositioning and wound care.
- General Condition:
- Warm and dry skin, decreased skin turgor, and mild swelling of the feet raise concerns regarding
hydration status and potential fluid overload, especially considering the patient's medication regimen
(furosemide).
- Other Indicators:
- Barrel chest and mild clubbing of fingers suggest possible chronic lung disease and chronic hypoxia.
- Cyanosis of the nail beds can indicate poor peripheral circulation and requires immediate attention.
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