Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?

Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes.

Alert and oriented, balanced intake and output, moist mucous membranes.

Respirations easy and unlabored, eats 50-75% of meals, vital signs stable.

Equal intake and output, denies pain or shortness of breath.

Answer and Explanation

The Correct Answer is A

A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.

B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.

C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.

D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.

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Correct Answer is B

Explanation

A. Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.

B. Regular ophthalmology exams are crucial for early detection of diabetic retinopathy, a leading cause of blindness in diabetes. Scheduling an eye appointment demonstrates proactive disease management.

C. Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.

D. Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.

A. "This is where you live now." B. "This is a safer place for you to live." C. "Your family said there is no one to care for you at home." D. "Tell me what you like to cook for dinner."

Correct Answer is D

Explanation

A. Stating "this is where you live now" may cause frustration.

B. Telling the patient it is safer does not acknowledge their emotions.

C. Mentioning family decisions may increase anxiety.

D. This approach validates the patient’s feelings and redirects the conversation without causing distress.

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Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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