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    Hesi compass B exit proctored exam
    Select All That Apply

    An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenly becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement? Select all that apply.

    Explanation & Rationale

    A. Checking blood glucose is essential to determine if the client is experiencing hypoglycemia or hyperglycemia, given the symptoms of confusion and cool, clammy skin suggest hypoglycemia. B. Reporting changes in blood pressure is important to monitor for shock or other complications. C. Preparing to administer regular insulin is inappropriate initially; insulin would worsen hypoglycemia if that is the cause of symptoms. D. Observing respiratory rate and pattern is important as alterations may indicate metabolic disturbances or hypoglycemia severity. E. Palpating for bladder pain or distention is unrelated to the acute symptoms and not a priority in this scenario.

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