A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?

Fewer fingerstick glucose checks

Higher doses of insulin

Restriction of caloric intake

Increased oral fluid intake

Answer and Explanation

The Correct Answer is B

Choice A reason: Fewer fingerstick glucose checks are dangerous in acute hyperglycemia, as frequent monitoring tracks blood sugar trends, guiding insulin dosing. Reducing checks risks missing critical changes, worsening ketoacidosis or hyperosmolar state, making this intervention counterproductive for managing a diabetic emergency.

Choice B reason: Higher insulin doses are critical, as acute hyperglycemia in diabetes mellitus results from insulin deficiency, causing elevated blood glucose. Insulin lowers glucose by facilitating cellular uptake, preventing ketoacidosis or hyperosmolar coma, making this the priority intervention for rapid glycemic control.

Choice C reason: Restricting caloric intake addresses long-term diabetes management but not acute hyperglycemia, which requires insulin to lower blood glucose. Caloric restriction is secondary, as immediate glycemic control prevents complications, making this intervention less urgent during an acute episode.

Choice D reason: Increased oral fluid intake prevents dehydration but does not correct hyperglycemia. Insulin directly lowers blood glucose, addressing the primary issue, and fluids are supportive, making this intervention secondary to insulin administration for managing an acute hyperglycemic crisis.

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Correct Answer is A

Explanation

Choice A reason: Tapping the wrists performs Tinel’s sign, a diagnostic test for carpal tunnel syndrome. Tingling or pain in the median nerve distribution (thumb, index, middle fingers) indicates nerve compression, common in repetitive computer use. This directly assesses the condition, identifying nerve irritation, making it the most specific action.

Choice B reason: Comparing capillary refill assesses vascular perfusion, not nerve compression. Carpal tunnel syndrome involves median nerve entrapment, causing pain and paresthesia, not circulatory issues. Capillary refill is normal in this condition, making this action irrelevant for diagnosing the client’s hand pain and numbness.

Choice C reason: Determining sleeping position may identify symptom triggers, like wrist flexion, but is not a diagnostic test. Carpal tunnel syndrome requires physical assessment, like Tinel’s sign, to confirm median nerve compression. Sleeping position is secondary, providing context but not direct evidence of the condition.

Choice D reason: Applying pressure over the ulnar artery assesses circulation, not median nerve compression. Carpal tunnel syndrome affects the median nerve, causing pain and tingling, not ulnar nerve or vascular issues. This action is irrelevant, as it does not evaluate the neurological symptoms described by the client.

A. Severe headache with photosensitivity B. Right lower abdomen rebound tenderness C. Petechial hemorrhage under client’s eyes D. Dark green colored emesis

Correct Answer is B

Explanation

Choice A reason: Severe headache with photosensitivity suggests meningitis or dehydration but is less urgent than rebound tenderness, which indicates peritonitis. In acute abdominal pain, neurological symptoms are secondary to potential surgical emergencies like appendicitis, requiring immediate reporting for possible operative intervention.

Choice B reason: Right lower abdomen rebound tenderness indicates peritoneal irritation, likely appendicitis, in acute abdominal pain. This surgical emergency risks rupture, causing peritonitis or sepsis, necessitating immediate reporting to the provider for urgent imaging or surgery, making it the priority finding over other symptoms.

Choice C reason: Petechial hemorrhage under the eyes suggests coagulopathy or increased intracranial pressure but is less specific to acute abdominal pain. Rebound tenderness directly indicates a surgical emergency like appendicitis, making petechiae a secondary concern requiring evaluation after addressing peritoneal signs.

Choice D reason: Dark green emesis indicates bile or obstruction but is less urgent than rebound tenderness, which signals peritonitis. Vomiting is managed with fluids, but tenderness suggests a surgical condition like appendicitis, requiring immediate reporting to prevent complications like perforation.

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A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to awake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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