A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
Acetone breath.
Confusion.
Polydipsia.
Hot, dry skin.
The Correct Answer is B
Choice A rationale:
Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.
Choice B rationale:
Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.
Choice C rationale:
Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.
Choice D rationale:
Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Use an albuterol inhaler.
Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.
Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.
Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.
Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.
Correct Answer is A
Explanation
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
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