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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suggest the visitors stay a bit longer to provide support and distraction. – Noise and stimulation can worsen migraines.
B. Suggest the patient ambulates in the hallway to become fatigued, so they can rest. – Movement may increase pain.
C. Turn the lights and television off except for a night light. – Correct Answer. Migraines are worsened by light and noise, so a dark and quiet environment is best.
D. Turn on the television to be used as a distractor for the patient. – Bright lights and sound can aggravate symptoms.
Correct Answer is A
Explanation
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
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