A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test.

Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Thirst.

Confusion.

Shakiness.

Cool skin.

Answer and Explanation

The Correct Answer is A

Thirst is a common symptom of hyperglycemia, or high blood sugar, in clients with diabetes mellitus.
Choice B is wrong because confusion can be a symptom of both hyperglycemia and hypoglycemia (low blood sugar).
Choice C is wrong because shakiness is more commonly associated with hypoglycemia.
Choice D is wrong because cool skin is not a common symptom of hyperglycemia.

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Correct Answer is C

Explanation

When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.

A. Heightened sense of pain. B. Increased nighttime sleeping. C. Decreased sense of balance. D. Nighttime urinary incontinence.

Correct Answer is C

Explanation

As people age, they may experience a decrease in their sense of balance. This can increase the risk of falls and injuries.
Choice A is wrong because older adults may actually have a decreased sense of pain.
Choice B is wrong because older adults may experience changes in their sleep patterns, including difficulty falling asleep or staying asleep.
Choice D is wrong because while urinary incontinence can be a common issue among older adults, it is not limited to nighttime.

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A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?

Correct Answer is C

Explanation

What findings should the nurse expect when assessing an older adult client?

Correct Answer is C

Explanation

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A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test.

Which of the following findings should indicate to the nurse that the client has hyperglycemia?