A nurse is assessing a client who has a blood glucose level of 265 mg/dL (74 to 106 mg/dL). Which of the following clinical manifestations is associated with this finding?
Shakiness
Confusion
Thirst
Diaphoresis
The Correct Answer is C
A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.
B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.
C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.
D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Instill prescribed drops whenever your eyes feel irritated.": Eye drops for glaucoma are prescribed on a strict schedule to maintain consistent intraocular pressure reduction. Administering them only when irritation occurs can lead to ineffective treatment and progression of optic nerve damage.
B. "Apply gentle pressure to the outer corner of your eye following eye drop administration.": The correct technique is to apply gentle pressure to the inner corner (punctal area) of the eye to prevent systemic absorption of the medication. Pressure at the outer corner does not prevent systemic effects and is not recommended.
C. "Place the tip of the container in the lower conjunctival sac to administer.": Eye drops should be placed in the lower conjunctival sac, but the instruction is incomplete without guidance on avoiding contact with the eye surface to prevent contamination. Proper placement technique includes holding the dropper above the sac without touching the eye.
D. "Wait 5 minutes before administering different eye drop medications": Waiting 5 minutes between different eye drops allows adequate absorption and prevents one medication from washing out the other. This practice optimizes therapeutic effects and minimizes interactions between multiple ocular medications.
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day: Visitor restrictions for clients with sealed radiation implants typically focus on limiting cumulative exposure to radiation rather than a strict daily time limit. The exact duration may vary, but monitoring personal exposure is more critical for staff safety.
B. Remove dirty linens from the room after double bagging: For sealed radiation implants, the radioactive source remains contained, and linens are not highly radioactive. Standard precautions are sufficient, so special double-bagging is not required unless the linens are contaminated with bodily fluids.
C. Wear a dosimeter film badge while in the client's room: Staff who care for clients with sealed radiation implants must wear a dosimeter to monitor cumulative radiation exposure. This ensures that occupational safety limits are not exceeded and provides documentation of exposure levels, which is a key safety measure in the plan of care.
D. Ensure family members remain at least 1 m (3.2 feet) from the client: Family members may need limited exposure, but strict distance alone is not sufficient for safety or required for all types of sealed implants. Staff exposure monitoring via dosimeter is more critical, as they spend more time in the room and are at greater risk for cumulative exposure.
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