A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?

Blood glucose using a glucometer

Pupillary reaction to light

Deep tendon reflexes

Liver function laboratory values

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.

Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.

Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.

Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

The correct answer is A, C, D

Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.

Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.

Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.

Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.

Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.

A. Unilateral weakness B. Stiff neck C. Photophobia D. Epigastric pain E. Lethargy

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Unilateral weakness is an incorrect finding, because it is more indicative of a stroke or a brain tumor than encephalitis. Encephalitis is an inflammation of the brain that can cause neurological symptoms, but they are usually bilateral and symmetrical.

Choice B reason: Stiff neck is a correct finding, because it is a sign of meningeal irritation, which can occur in encephalitis due to the involvement of the meninges (the membranes that cover the brain and spinal cord).

Choice C reason: Photophobia is a correct finding, because it is another sign of meningeal irritation, which can cause sensitivity to light and sound.

Choice D reason: Epigastric pain is an incorrect finding, because it is not related to encephalitis. Epigastric pain is more likely to be caused by a gastrointestinal disorder, such as gastritis or peptic ulcer.

Choice E reason: Lethargy is a correct finding, because it is a sign of altered mental status, which can occur in encephalitis due to the damage to the brain tissue.

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A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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