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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A This statement indicates an understanding of the right to refuse treatment at any time, even after it has been initiated. Clients have the right to change their mind about treatment options and can withdraw their consent at any stage of treatment.
B. This statement suggests a misunderstanding of informed consent. Informed consent means the client understands the risks, benefits, and alternatives to a proposed treatment or procedure. Signing a consent form because one believes there are no other options does not reflect an informed decision- making process.
C. This statement indicates a misconception about treatment options. Clients have the right to refuse a specific treatment plan or procedure and explore other options or seek a second opinion. Refusal of one treatment does not necessarily preclude the possibility of pursuing alternative treatments.
D. This statement indicates a misunderstanding of the risks associated with treatment. It's crucial for clients to understand both the potential benefits and possible adverse effects of any treatment they undergo. Radiation treatment, like any medical intervention, carries risks that should be weighed against potential benefits.
Correct Answer is A
Explanation
A Advancing the weaker leg forward to the quad cane first indicates that the client understands the proper sequence of using the cane to support their weaker side. This action provides stability and reduces the risk of falls or imbalance.
B. Holding the cane with the opposite hand of the weaker side (right hand, in this case) is crucial to provide proper support and balance while walking. This distributes weight evenly and enhances stability.
C. Taking a step with the stronger foot first does not effectively support the weaker side and can lead to imbalance or falls, especially for a client with left-sided weakness.
D. While moving the cane ahead with each step is necessary, the distance of two feet is not specified in proper cane use. The cane should move forward incrementally with each step to maintain stability and support.
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