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 C

Explanation

C. Heat therapy can help relax muscles and relieve stiffness in the joints, making it easier to move around and start the day.

A While it's important to maintain a regular sleep schedule, short naps may actually help manage fatigue associated with the condition

B. Cold therapy, such as using ice packs, can actually help reduce inflammation and relieve pain in inflamed joints for many individuals with RA.

D. Decreasing the amount of iron in the diet is not advisable without specific medical guidance.

A. Clear items from the client's surrounding area. B. Lower the client to the floor. C. Obtain the client's vital signs. D. Loosen the client's restrictive clothing.

Correct Answer is B

Explanation

A Clearing the area is essential to prevent injury during a seizure. The client may move or thrash around, and any objects nearby (e.g., furniture, medical equipment, or sharp objects) can potentially cause harm. However, this can be done after lowering teh client.

B. This action is crucial to protect the client from injury during the seizure. It provides a safe environment for the client to have the seizure without risk of falling or hitting their head on objects.

C. Assessing vital signs can wait until after the seizure has ended and the client's immediate safety has been ensured. During a seizure, the nurse should focus on managing the seizure and preventing complications.

D. This action is important for comfort and safety but is secondary to ensuring a safe environment and managing the seizure itself.

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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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