A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
Increased thirst
Decreased urine output
Moist skin
Tremors
The Correct Answer is A
Rationale:
A. Increased thirst: Polydipsia, or excessive thirst, is a classic symptom of hyperglycemia. It results from the body's attempt to counteract dehydration caused by osmotic diuresis, which occurs when high glucose levels pull fluid into the urine.
B. Decreased urine output: Hyperglycemia typically causes polyuria (increased urine output), not decreased. High glucose concentrations in the blood lead to osmotic diuresis, resulting in frequent and excessive urination.
C. Moist skin: Hyperglycemia is more often associated with dry skin and mucous membranes due to fluid loss. Moist, clammy skin is more characteristic of hypoglycemia, particularly when it is accompanied by sweating and other adrenergic symptoms.
D. Tremors: Tremors are more commonly associated with hypoglycemia due to increased sympathetic nervous system activity. Hyperglycemia usually develops more gradually and does not typically produce tremors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Prepare to intubate the client with an endotracheal tube: Intubation is an invasive intervention typically reserved for clients with severe or rapidly deteriorating respiratory failure. It is not the first step in managing hypoxia when simpler oxygen delivery methods may be effective.
B. Place a nonrebreather face mask: This is the priority action because a nonrebreather mask delivers high-concentration oxygen (up to 95–100%) and can rapidly correct hypoxia. It is the most appropriate next step when a nasal cannula at 5 L/min is insufficient.
C. Obtain a prescription for arterial blood gases: While important for assessing the severity of hypoxia and guiding further treatment, this diagnostic action does not immediately address the client’s oxygenation needs.
D. Apply noninvasive positive-pressure ventilation: This intervention is beneficial for clients with certain conditions like COPD or heart failure but may not be the first-line response for general hypoxia. A nonrebreather mask is simpler and faster to apply in an acute setting.
Correct Answer is B
Explanation
Rationale:
A. "You will drink a contrast solution 30 minutes prior to the procedure.": Contrast solutions are used for imaging studies like CT scans, not for bronchoscopies. Bronchoscopy is a visual examination of the airways and does not require contrast ingestion beforehand.
B. "You will not be able to eat or drink after the procedure until you are able to cough.": After a bronchoscopy, the gag and cough reflexes are temporarily suppressed due to local anesthesia. Eating or drinking before these reflexes return increases the risk of aspiration, so this is an essential safety measure.
C. "The purpose of this procedure is to remove excess fluid from your lungs.": Bronchoscopy is primarily used for visualizing the airways, obtaining tissue samples, or removing obstructions. Thoracentesis, not bronchoscopy, is the procedure used to remove fluid from the pleural space.
D. "You will need to lie on your back for 4 to 6 hours following the procedure.": Prolonged supine positioning is not necessary after bronchoscopy. Clients are typically monitored in a semi-Fowler’s position until sedation wears off and airway protective reflexes return.
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