A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Poor skin turgor.

Fruity breath odor.

Kussmaul respirations.

Irritability.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

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Correct Answer is C

Explanation

Choice A rationale:

Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.

Choice B rationale:

Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.

Choice C rationale:

The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.

Choice D rationale:

Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.

A. Increase intake of dairy products. B. Drink ten glasses of water each day. C. Decrease daily fiber intake to 20 grams. D. Encourage intake of clear carbonated fluids.

Correct Answer is B

Explanation

Choice A rationale:

Increasing the intake of dairy products is not recommended for a client with irritable bowel syndrome (IBS) as dairy can exacerbate symptoms in some individuals, particularly if they are lactose intolerant.

Choice B rationale:

Drinking ten glasses of water each day is a helpful recommendation for clients with IBS. Staying hydrated can aid in digestion and help alleviate symptoms like constipation.

Choice C rationale:

Decreasing daily fiber intake to 20 grams is not advisable for IBS management. Adequate fiber intake is essential for maintaining bowel regularity and overall gut health. Instead, it is recommended to focus on soluble fiber and gradually increase fiber intake to avoid exacerbating symptoms.

Choice D rationale:

Encouraging the intake of clear carbonated fluids is not ideal for clients with IBS. Carbonated beverages can cause bloating and gas, potentially worsening symptoms in individuals with sensitive digestive systems. It is better to recommend non-carbonated, non-caffeinated fluids for hydration.

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A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is providing information about maintaining a special diet with a client who has irritable bowel syndrome. Which of the following information should the nurse include?

Correct Answer is B

Explanation

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