A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

Kussmaul respirations

Increased urine output

Cool, clammy skin

Acetone breath

Answer and Explanation

The Correct Answer is C

C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.

A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.

B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.

D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.

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Correct Answer is A

Explanation

A This response addresses a potential cause of exercise-induced hypoglycemia. Clients with type 1 diabetes often need to adjust their insulin dose or carbohydrate intake before exercise to prevent hypoglycemia. Asking about insulin adjustment is relevant to assess whether the client took appropriate precautions.

B. While exercise can cause fatigue, feeling diaphoretic, having palpitations, and extreme exhaustion are not normal responses after exercise, especially for someone with type 1 diabetes. This response does not address the potential cause of the symptoms.

C. This response addresses the importance of carbohydrate intake post-exercise to prevent or treat hypoglycemia. It encourages the client to reflect on their dietary choices following exercise, which can impact blood glucose levels.

D. While establishing a routine for exercise is beneficial for managing diabetes, this response does not address the immediate concern of hypoglycemia or provide guidance on managing the client's current symptoms.

A. Measure blood glucose every 2 hr. B. Instruct the client to lie flat C. Instruct the client to expect tingling in their extremities. D. Limit the client's fluid intake.

Correct Answer is B

Explanation

B. After a lumbar puncture, instructing the client to lie flat on their back for a period of time (often 1-2 hours) helps prevent complications such as headaches due to CSF leakage and promotes proper sealing of the puncture site.

A Monitoring blood glucose every 2 hours is not typically necessary immediately following a lumbar puncture unless the client has pre-existing diabetes or there are specific indications to monitor glucose levels

C Tingling in the extremities is not an expected or normal occurrence following a lumbar puncture. It could indicate neurological complications such as nerve irritation or damage, which would require prompt assessment and intervention.

D. The nurse should encourage adequate hydration unless contraindicated by the client's medical condition or specific post-procedure instructions.

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A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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