A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
Acetone breath.
Fever.
Serum glucose 800 mg/dL (74 to 106 mg/dL).
Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).
Insidious onset.
Correct Answer : B,C,E
Choice A rationale
Acetone breath is a characteristic symptom of diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). In DKA, the body produces ketones, leading to a fruity or acetone-like breath odor. HHS, on the other hand, does not typically involve significant ketone production.
Choice B rationale
Fever can be a manifestation of HHS, often due to an underlying infection or illness that precipitates the hyperglycemic state. Infections are common triggers for HHS, leading to elevated body temperature.
Choice C rationale
Serum glucose levels of 800 mg/dL are indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketoacidosis.
Choice D rationale
Serum bicarbonate levels of 15 mEq/L are more indicative of DKA rather than HHS. In HHS, bicarbonate levels are usually within the normal range because there is no significant ketoacidosis.
Choice E rationale
Insidious onset is a hallmark of HHS. The condition develops gradually over days to weeks, unlike DKA, which has a more rapid onset.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding bubble baths is a correct measure for preventing UTIs. Bubble baths can irritate the urethra and increase the risk of infection by allowing bacteria to enter the urinary tract. The warm, soapy water can disrupt the natural balance of bacteria in the genital area, making it easier for harmful bacteria to thrive and cause infections.
Choice B rationale
Voiding after sexual intercourse is a correct measure for preventing UTIs. During sexual activity, bacteria can be introduced into the urethra. By urinating after intercourse, the client can help flush out any bacteria that may have entered the urinary tract, reducing the risk of infection.
Choice C rationale
Wiping the perineal area from back to front after urination is incorrect and indicates the need for further teaching. This practice can transfer bacteria from the anal area to the urethra, increasing the risk of UTIs. The correct method is to wipe from front to back to prevent the spread of bacteria.
Choice D rationale
Drinking at least 8 full glasses of liquid each day is a correct measure for preventing UTIs. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of infection. Drinking plenty of fluids ensures that the bladder is emptied regularly, which helps prevent the buildup of bacteria.
Correct Answer is A
Explanation
Choice A rationale
Abduction is the correct position for the client’s right leg following a right total hip arthroplasty. This position helps prevent dislocation of the hip joint by keeping the leg away from the midline.
Choice B rationale
Internal rotation should be avoided as it can increase the risk of hip dislocation. This position places stress on the new hip joint.
Choice C rationale
External rotation is also not recommended as it can lead to dislocation of the hip joint. Proper alignment is crucial for healing.
Choice D rationale
Adduction, or moving the leg towards the midline, should be avoided as it significantly increases the risk of hip dislocation. Keeping the leg in abduction helps maintain joint stability.
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