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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Activity level of bowel sounds:
Bowel sounds are important to assess, but they may not directly influence or be influenced by the abdominal pain associated with chronic pancreatitis.
B. Eating patterns and dietary intake.
Clients with chronic pancreatitis often experience abdominal pain exacerbated by the intake of food, especially fatty meals. Monitoring the client's eating patterns and dietary intake is crucial for identifying triggers that may worsen the abdominal pain. By understanding the relationship between food intake and pain, the nurse can provide guidance on dietary modifications to help manage the symptoms.
C. Level and amount of physical activity:
While physical activity is important for overall health, it may not be the primary factor contributing to or alleviating the abdominal pain in a client with chronic pancreatitis.
D. Color and consistency of feces:
Monitoring the color and consistency of feces is important for assessing pancreatic function, but it may not be the most immediate factor to address in the context of managing abdominal pain. Dietary patterns are more directly related to pain management in this case.
Correct Answer is D
Explanation
A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.
B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.
C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.
D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

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