A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Poor skin turgor.

Fruity breath odor.

Kussmaul respirations.

Irritability.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

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Correct Answer is B

Explanation

Choice A rationale:
Is not a safe fall prevention strategy. Securing cords under carpeting can create tripping hazards. It is better to keep cords away from commonly used walking paths or use cord covers to prevent falls.
Choice B rationale:
Purchasing a skid-proof bathtub mat is a good fall-prevention strategy for an older adult client. It helps prevent slipping and falling in the bathroom, which is a common area for accidents in older adults.
Choice C rationale:
Is not a recommended fall prevention strategy. Leather soles can be slippery on smooth surfaces, increasing the risk of falls. Instead, the client should wear shoes with rubber soles that provide better traction.
Choice D rationale:
Is not the best option. Throw rugs, even with rubber backing, can still shift or bunch up, posing a tripping hazard. It's safer to avoid using throw rugs altogether or ensure they are firmly secured to the floor.

A. "I will take three sitz baths a week to relieve my discomfort.". B. "I should cleanse my lesions with 1/2 strength peroxide.". C. "I will avoid sexual activity until my lesions are healed.". D. "I am not contagious once I begin antiviral medication.".

Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

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A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client about fall prevention strategies at home. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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