A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
Absence of Chvostek's sign
Presence of Kussmaul respirations
Presence of diaphoresis
Absence of urinary ketones
The Correct Answer is B
Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial muscles in response to tapping the facial nerve and is typically associated with low blood calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis (DKA), a severe complication of diabetes characterized by significantly high blood sugar levels and the presence of ketones in the blood and urine. This type of breathing pattern is the body's attempt to compensate for the acidic state caused by high blood sugar and the buildup of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating, which can occur due to various reasons such as physical activity, heat, stress, or certain medical conditions. While hyperglycemia can cause symptoms like increased thirst and frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates the body is breaking down fat for energy, which commonly occurs during periods of insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia to be present without ketones in the urine, especially in the early stages or when the body is still managing blood sugar levels without significant ketone production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1000"]
Explanation
To lose 0.9 kg (2 lb) of body fat per week, the client needs to create a weekly caloric deficit of 7000 calories (3500 x 2).
This means that he needs to reduce his daily caloric intake by 1000 calories (7000 / 7).
The nurse should instruct the client to calculate his current daily caloric intake and then subtract 1000 calories from that amount. The nurse should also advise the client to eat a balanced diet and exercise regularly to achieve his weight loss goal.
Correct Answer is B
Explanation
Choice A Reason:
The client had a hemorrhoidectomy 1 year ago is appropriate. While hemorrhoids involve bleeding in the anal area, the blood from hemorrhoids is usually visibly present and not considered "occult" or hidden. A history of hemorrhoidectomy is less likely to cause a false-positive occult blood test result as the bleeding is typically visible.
Choice B Reason:
The client takes ibuprofen for headaches is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can irritate the gastrointestinal tract, leading to small amounts of bleeding. This bleeding, although not typically visible, can be detected by occult blood tests, resulting in a false-positive result
Choice C Reason:
The client has a history of breast cancer is incorrect. A history of breast cancer, in itself, is not directly related to gastrointestinal bleeding that would lead to a false-positive result in an occult blood test. Occult blood screening tests primarily detect bleeding from the gastrointestinal tract.
Choice D Reason:
The client consumed citrus juice 3 days before the test is incorrect. Consumption of citrus juice is not known to cause false-positive results in occult blood screening tests. These tests are designed to detect blood specifically from the gastrointestinal tract and aren't affected by citrus juice consumption.
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