A nurse is assessing a client who has a blood glucose level of 265 mg/dL (74 to 106 mg/dL). Which of the following clinical manifestations is associated with this finding?
Shakiness
Confusion
Thirst
Diaphoresis
The Correct Answer is C
A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.
B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.
C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.
D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
Identify the ordered dose and the available concentration
Ordered Dose: 30 g
Available Concentration: 10 g per 15 mL
Calculate the volume to administer per dose using the Dose/Have method
Amount to administer = (Ordered Dose ÷ Dose on Hand) × Quantity
Quantity corresponding to the Dose on Hand = 15 mL
Volume = (30 ÷ 10) × 15
= 3 × 15
= 45 mL
Correct Answer is D
Explanation
A. Blood pressure 94/68 mm Hg: While slightly on the lower end for a 7-year-old, mild hypotension may not yet be present in severe dehydration because children often maintain blood pressure until significant fluid loss occurs. Blood pressure alone is not the earliest or most sensitive indicator of severe dehydration.
B. Urinary output 30 mL/hr: Normal urinary output for a child is approximately 1 mL/kg/hr. A child with severe dehydration typically has markedly reduced urine output (oliguria), so 30 mL/hr is still be within a low-normal range depending on the child’s weight
C. Respiratory rate 24/mn: This respiratory rate is within normal limits for a 7-year-old (approximately 18–25 breaths/min). It does not reflect compensation for dehydration or hypovolemia and is not a reliable indicator of severe fluid loss.
D. Heart rate 152/min: Tachycardia is an early and sensitive sign of hypovolemia in children. A heart rate of 152/min is significantly elevated for a 7-year-old, indicating compensatory mechanisms to maintain perfusion in response to severe dehydration.
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