A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

Report of decreased urinary output

Random blood glucose 126 mg/dL

Clammy skin

History of poor wound healing

Answer and Explanation

The Correct Answer is D

A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.

B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.

C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.

D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.

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Correct Answer is D

Explanation

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

A. "Sweating can occur with hypoglycemia." B. "My son might complain of feeling shaky when he has a low blood glucose level." C. "My son might have nausea and vomiting with hypoglycemia." D. "The onset of low blood glucose usually occurs rapidly."

Correct Answer is C

Explanation

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.

D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.

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A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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