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 A

Explanation

Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.

A. A pearly, waxy nodule. B. An irregular border on a variegated-colored lesion. C. A firm, nodular, crusty, or ulcerated lesion. D. A weeping vesicle.

Correct Answer is A

Explanation

the correct answer is Choice A.

Choice A rationale: Basal cell carcinoma (BCC) is a type of skin cancer that develops in basal cells, a type of cell within the skin that produces new skin cells 1.One of the common symptoms of BCC is a pearly white, skin-colored or pink bump 1.This can also appear as a shiny or pearly nodule with a smooth surface 2.Therefore, a pearly, waxy nodule is a characteristic lesion of basal cell carcinoma

Choice B rationale: An irregular border on a variegated-colored lesion is more commonly associated with melanoma, another type of skin cancer, rather than basal cell carcinoma 1.While BCC can have a variety of appearances, an irregular border on a variegated-colored lesion is not typically characteristic of BCC

Choice C rationale: A firm, nodular, crusty, or ulcerated lesion can be a sign of several types of skin conditions, including squamous cell carcinoma, another type of skin cancer 1.While BCC can sometimes appear as a firm nodule 1 , the description of a crusty or ulcerated lesion is not as characteristic of BCC as a pearly, waxy nodule

Choice D rationale: A weeping vesicle is not typically associated with basal cell carcinoma 1.BCC lesions are more likely to appear as a shiny bump or nodule, or a flat, scaly patch 1.A weeping vesicle could be indicative of a different skin condition

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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?

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