The nurse administered insulin lispro to a client 45 minutes ago. Which finding should cause the nurse to assess for hypoglycemia?
The client reports increased hunger.
The client reports palpitations.
The client reports a headache.
The client reports joint pain.
The Correct Answer is B
A. The client reports increased hunger: Hunger can occur as blood glucose begins to fall, but it is an early and nonspecific adrenergic sign and may not reliably indicate clinically significant hypoglycemia. It requires monitoring but is less urgent than symptoms linked to neuroglycopenia or autonomic overactivation.
B. The client reports palpitations: Palpitations reflect sympathetic nervous system activation due to rapid declines in plasma glucose, triggering catecholamine release. This response occurs during acute hypoglycemia and signals that glucose levels may be dropping to a dangerous range, requiring immediate assessment and intervention.
C. The client reports a headache: Headache may develop with hypoglycemia but tends to occur later as neuroglycopenia progresses. It is less specific and does not usually precede severe or acute hypoglycemic episodes as reliably as adrenergic symptoms such as palpitations or tremors.
D. The client reports joint pain: Joint pain is not physiologically associated with hypoglycemia and is unrelated to insulin’s metabolic effects. It does not reflect glucose fluctuations or autonomic activation and therefore would not prompt hypoglycemia assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Amount of alcohol consumed: Alcohol can interact with many medications, affecting metabolism, efficacy, and toxicity. Including alcohol use in the medication profile allows the nurse to anticipate potential drug interactions and counsel the client on safe use.
B. Prescription medications: Documenting all prescribed medications is essential to prevent drug interactions, duplications, and adverse effects. This information helps the nurse coordinate safe pharmacotherapy and verify that prescribed doses are appropriate.
C. Favorite time to take medications: While the client’s preferred timing may support adherence, it is not clinically relevant to include in the medication profile for safety, interaction, or therapeutic monitoring purposes.
D. Use of over-the-counter drugs: Over-the-counter medications can interact with prescription drugs or contribute to adverse effects. Including them in the profile ensures a complete understanding of the client’s medication exposure.
E. Use of vitamin supplements: Vitamins and herbal supplements may affect drug metabolism or interact with prescription medications. Recording these supports comprehensive medication reconciliation and helps prevent potential toxicity or diminished drug efficacy.
Correct Answer is B
Explanation
A. Diarrhea: Gastrointestinal upset, including diarrhea, is a common and generally mild side effect of metformin. While uncomfortable, it is usually self-limiting and does not indicate a life-threatening condition.
B. Shallow breathing: Shallow or labored breathing is concerning because it may indicate lactic acidosis, a rare but potentially fatal complication of metformin. Lactic acidosis occurs due to accumulation of lactate when metformin impairs mitochondrial gluconeogenesis, requiring immediate medical evaluation.
C. Nausea: Nausea is a common gastrointestinal side effect of metformin. While it may contribute to dehydration or decreased oral intake, it is usually manageable and does not require emergent intervention unless severe.
D. Metallic taste: A metallic taste in the mouth is a minor and non-life-threatening side effect of metformin. It does not pose significant health risks and is not typically a cause for urgent concern.
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