A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
Positive Trousseau's sign
Dizziness upon standing
Tingling of the fingers
Increased respiratory rate
The Correct Answer is D
Choice A Reason:
Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.
Choice B Reason:
Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.
Choice C Reason:
Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.
Choice D Reason:
Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Informing the client of the adverse effect of diarrhea is less common with clonidine use, especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal clonidine use.
Choice C Reason:
Advise the client about increased dry mouth. Dry mouth is a common adverse effect of clonidine, including the transdermal form. Patients should be informed about this so they can manage it effectively, for example, by drinking plenty of water or using sugar-free gum or candy to stimulate saliva production.
Choice D Reason:
Hypopigmentation is not a commonly reported issue with transdermal clonidine patches. However, local skin irritation or rash can occur at the site of the patch.
Correct Answer is A
Explanation
Choice A Reason:
Suction equipment is recommended. This is a crucial supply to have at hand. During or after a seizure, the client might have excessive secretions or vomit, which could potentially obstruct their airway. Suction equipment helps clear the airway and maintain breathing, making it an essential item to have bedside.
Choice B Reason:
Padded tongue blades is incorrect. The use of padded tongue blades during a seizure is not recommended. Placing anything inside the mouth during a seizure could cause injury or pose a risk of choking. Keeping the airway clear and ensuring the client's safety is more important than attempting to manipulate the tongue.
Choice C Reason:
Backboard is incorrect.Backboards are typically used for spinal immobilization in cases of suspected spinal injury, not specifically for seizure management. Unless there's a concurrent injury or trauma, a backboard wouldn't be routinely necessary for a client having a seizure.
Choice D Reason:
Wrist restraints is incorrect. Restraints are generally not used for managing seizures. Using restraints during a seizure could potentially cause harm, restrict movement, and increase the risk of injury to the client. Restraints are not considered appropriate or safe for managing seizures.
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