During a home visit the nurse learns that an older patient with type 2 diabetes mellitus and chronic renal failure is experiencing headache, polydipsia, and lethargy. What is the most important assessment that the nurse should make at this time?
1. Measure the patient's latest urine output.
2. Assess the patient's appetite and oral intake.
3. Measure the patient's current capillary blood glucose level.
4. Determine the amount of fluid the patient has ingested over the last few hours.
3. Measure the patient's current capillary blood glucose level.
Explanation: 1. The patient has chronic renal failure and may have minimal, if any, urine output.
2. The patient's appetite and oral intake will not help the nurse determine the cause of the patient's current symptoms.
3. Measuring the patient's capillary blood glucose level will help the nurse determine if the patient is developing hyperglycemic hyperosmolar nonketotic syndrome, a complication of type 2 diabetes mellitus.
4. Determining the amount of oral fluid intake the patient has had over the last few hours will not help the nurse determine the cause for the patient's current symptoms.
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