A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)
Acetone breath odor
Polydipsia
Inability to concentrate
Diaphoresis
Tremors
Correct Answer : C,D,E
Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.
B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.
C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.
D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.
E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
• Compartment syndrome: The child’s nondisplaced midshaft fracture of the radius and ulna places them at risk for compartment syndrome, whereby increased pressure within the muscle compartments impairs circulation and tissue perfusion. Early recognition is crucial to prevent permanent nerve or muscle damage.
• Paresthesia: The child reports tingling in the fingers, which indicates nerve involvement or compression—an early warning sign of compartment syndrome. Monitoring for paresthesia helps the nurse identify worsening neurovascular compromise promptly.
Rationale for Incorrect Choices
• Osteomyelitis: Infection of the bone is unlikely immediately after a closed nondisplaced fracture without open wounds or surgical intervention. There is no evidence of systemic infection at this stage.
• Nonunion: Fracture nonunion is a long-term complication that occurs if healing fails over weeks to months. The child’s fracture is recent, so immediate risk is low.
• Physical damage: While trauma caused the fracture, “physical damage” is a broad term and does not specify a complication requiring acute monitoring.
• Ecchymosis: Bruising indicates soft tissue injury but does not predict compartment syndrome or other severe complications.
• Type of fracture: While important for diagnosis and treatment planning, the fracture type (nondisplaced) does not directly indicate the acute risk for neurovascular compromise.
• Location of fracture: The midshaft location contributes to fracture management but is not as clinically relevant as the early signs of compartment syndrome, such as paresthesia.
Correct Answer is A
Explanation
Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.
B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.
C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.
D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.
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