A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

Hyperactive bowel sounds.

Anxiety and sighing.

Dark yellow urine.

Myalgia in wrists and hands.

Answer and Explanation

The Correct Answer is C

A. Hyperactive bowel sounds.
Hyperactive bowel sounds are more suggestive of gastrointestinal issues, such as intestinal hypermotility or increased peristalsis. While diabetes can affect the gastrointestinal system, hyperactive bowel sounds are not a specific indicator of the symptoms described by the client.

B. Anxiety and sighing.
Anxiety and sighing are more indicative of emotional or psychological factors rather than dehydration. While stress can impact blood sugar levels in individuals with diabetes, anxiety and sighing are not direct signs of the dehydration that may be associated with the reported symptoms.

C. Dark yellow urine.
Dark yellow urine can be a sign of concentrated urine, suggesting dehydration. In diabetes, especially when blood sugar levels are elevated, increased urine production (polyuria) can lead to dehydration. Dark yellow urine may indicate that the urine is more concentrated due to a lack of fluid intake.

D. Myalgia in wrists and hands.
Myalgia in the wrists and hands is not a typical symptom of dehydration related to diabetes. It could be associated with various conditions, such as musculoskeletal issues or nerve-related problems. This symptom is less likely to be directly linked to the reported weakness and palpitations.

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Correct Answer is C

Explanation

A. Begin continuous observation for transient episodes of neurologic dysfunction:
While continuous observation is important, the priority is to notify the stroke team for immediate assessment and management.

B. Place an indwelling urinary catheter and measure strict intake and output:
Monitoring intake and output is an important aspect of nursing care, but it is not the immediate priority when the client is presenting with signs and symptoms suggestive of a stroke.

C. Notify the stroke team to assist with acute assessment and management.
The client's symptoms, including an uneven smile with facial droop to the right side, weaker hand grasp strength on the right, and sudden, severe headache, are indicative of potential stroke symptoms. Quick notification of the stroke team is crucial to facilitate a rapid and comprehensive assessment. Time is a critical factor in the management of stroke, and prompt intervention can improve outcomes.

D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment:
While positioning is important for maintaining physiological stability, it is not the immediate priority in the context of a potential stroke. Notifying the stroke team for rapid assessment and intervention takes precedence.

A. Hypovolemia and electrocardiographic (ECG) changes. B. Uremic irritation of mucous membranes and skin surfaces. C. Side effects of total parental nutrition (TPN) and Intralipids. D. Elevated creatinine and blood urea nitrogen (BUN)

Correct Answer is A

Explanation

A. Hypovolemia and electrocardiographic (ECG) changes:
During the diuretic phase of AKI, there is an increased urine output, and the risk of dehydration and hypovolemia is elevated. The nurse should closely monitor fluid balance to prevent dehydration, and ECG changes may occur due to electrolyte imbalances (such as hypokalemia) associated with diuresis.

B. Uremic irritation of mucous membranes and skin surfaces:
Uremic symptoms are more prominent in the oliguric phase of AKI when waste products accumulate in the blood. In the diuretic phase, the focus shifts more toward managing fluid and electrolyte balance.

C. Side effects of total parental nutrition (TPN) and Intralipids:
TPN and Intralipids are not directly related to the diuretic phase of AKI. Monitoring for side effects of TPN and Intralipids may be relevant in other clinical contexts but is not the primary concern in the diuretic phase.

D. Elevated creatinine and blood urea nitrogen (BUN):
Monitoring creatinine and BUN levels is important for assessing kidney function, but in the diuretic phase, the focus shifts to managing fluid and electrolyte balance. The risk of hypovolemia and electrolyte imbalances is more immediate during this phase.

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A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

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Correct Answer is A

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