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)
Inability to concentrate
Polydipsia
Tremors
Acetone breath odor
Diaphoresis
Correct Answer : A,C,E
Choice A reason: Inability to concentrate is a common symptom of hypoglycemia in type 1 diabetes, as low blood glucose impairs brain function, leading to confusion and difficulty focusing. This neuroglycopenic symptom results from insufficient glucose for cerebral energy, making it a critical indicator requiring prompt intervention like glucose administration.
Choice B reason: Polydipsia is associated with hyperglycemia, not hypoglycemia, in type 1 diabetes. It results from osmotic diuresis due to high blood glucose, causing dehydration and thirst. This symptom does not indicate low blood sugar, making it incorrect for identifying hypoglycemia in this scenario.
Choice C reason: Tremors are a hallmark of hypoglycemia, caused by the sympathetic nervous system’s response to low blood glucose, triggering catecholamine release. This leads to shakiness, a common adrenergic symptom, signaling the need for immediate glucose to restore normal levels, making it a correct indicator.
Choice D reason: Acetone breath odor is linked to diabetic ketoacidosis (DKA), a complication of hyperglycemia, not hypoglycemia. It results from ketone production during fat metabolism in uncontrolled diabetes. This finding is irrelevant to low blood sugar, making it incorrect for this scenario.
Choice E reason: Diaphoresis, or excessive sweating, is a classic hypoglycemia symptom due to autonomic activation from low blood glucose. The body releases adrenaline, causing sweating as a stress response. This reliable indicator prompts urgent treatment to prevent severe complications, making it a correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Absence seizures lack an aura, unlike focal seizures. They involve brief, sudden lapses in consciousness due to generalized cortical discharges, without premonitory symptoms, making this incorrect for educating parents about the characteristics of absence seizures in children.
Choice B reason: Absence seizures last 5-20 seconds, not 30-60 seconds. These brief staring spells are caused by spike-wave discharges on EEG. Prolonged duration suggests other seizure types, making this inaccurate for teaching parents about absence seizure presentation and duration.
Choice C reason: Absence seizures are managed with anticonvulsants like ethosuximide, not surgery. Surgical intervention is for refractory focal seizures, not generalized absence seizures, which respond to medication. This is incorrect for educating parents about treatment options for absence seizures.
Choice D reason: Absence seizures cause a daydreaming appearance, with staring and brief unresponsiveness due to synchronized cortical discharges. This hallmark symptom, lasting seconds, is critical for parents to recognize, aiding identification and management of absence seizures in school settings.
Correct Answer is B
Explanation
Choice A reason: Assigning a health care surrogate does not always require legal consultation, as forms are often available without attorney involvement. While legal advice can clarify complex cases, it is not mandatory, making this statement misleading and incorrect for general advance directive education.
Choice B reason: A health care surrogate makes decisions when the client is incapacitated, as specified in advance directives. This ensures the client’s wishes are followed, aligning with the purpose of surrogacy in healthcare planning, making it accurate and essential information for the teaching session.
Choice C reason: Advance directives can be changed at any time by a competent client, provided the changes are documented and communicated. Stating they cannot be changed is incorrect, as flexibility is a key feature, making this misinformation inappropriate for teaching.
Choice D reason: Advance directives are generally honored across states, though specific requirements may vary. Stating they are only valid in one state is overly restrictive and incorrect, as reciprocity is common, making this an inaccurate point for advance directive education.
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