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nurses’ notes for an older client who was admitted to D. Health History Nurses’ Notes Physician’s Orders Lab Tests 1420: 87-year-old client admitted to the ED from independent living apartment with new report of episodic acute confusion, urinary frequency and incontinence, and severe fatigue. Child states that client is independent in ADLs and has no history of dementia. Client was admitted last month to the hospital for 3 days after a mild stroke but had no residual symptoms. Has had type 2 diabetes mellitus for about 15 years. Admission vital signs: T 100.80F (38.2.C), HR 96 BPM. RR 20 bpm, BP 98/46, Spo2 90% on RA. Alert and oriented x 1 (person). Lungs clear; S1 and Sz present with no murmurs or gallops. Extremities cool with capillary refill greater than 5 seconds. Both legs slightly mottled with 1+ edema. 1450: Urinalysis shows numerous WBCs, casts, and few CBCs. Cath urine specimen for culture and sensitivity sent to laboratory. Peripheral IV of 5%D/NS started in left forearm. O2 2L/min via NC administered. 1530: Normal BMP and CBC results, except for WBCs of 16,000/mm3 (16 x 109/L) with bands greater than 10%. Complete the following sentence from the list of options provided. Based on the client’s health condition, the nurse determines that the priority for the client is to monitor for the potentially life-threatening complication of [- – diabetic ketoacidosis orthostatic hypotension . dehydration sepsis cardiogenic shock A: Diabetic ketoacidosis O B: Orthostatic hypotension C: Dehydration D: Sepsis E: Cardiogenic shock

 
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