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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. A client whose medications to manage Parkinson's disease are no longer effective.
Rationale:
A) A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin:
While this client has a significant medical issue, the primary concern here is financial rather than palliative. Palliative care focuses on providing relief from symptoms and improving quality of life for those with serious illnesses. Addressing the client's financial issues might involve social services or community resources rather than palliative care.
B) A client who has Meniere's disease and cannot safely ambulate due to vertigo:
Meniere's disease, while debilitating, may not necessarily require palliative care unless the symptoms are severely impacting the client's quality of life in a way that is not manageable with current treatments. Palliative care could be considered if the disease is severely limiting function and other supportive care is needed.
C) A client who had a stroke and cannot eat or drink without choking:
This client is experiencing a significant functional impairment due to the stroke, which might benefit from rehabilitative services rather than palliative care. Palliative care would be more appropriate if the client's condition is progressive, severe, and not responsive to treatment, leading to a focus on comfort and quality of life.
D) A client whose medications to manage Parkinson's disease are no longer effective:
When medications for Parkinson's disease are no longer effective, the client may be experiencing advanced symptoms and a decline in quality of life. Palliative care can provide symptom management, support, and enhance the client's quality of life when conventional treatments are no longer effective in controlling symptoms.
Correct Answer is B
Explanation
Choice A rationale:
A PT (Prothrombin Time) of 12 seconds is not indicative of the effectiveness of heparin therapy for a pulmonary embolism. PT measures the extrinsic pathway of the coagulation cascade, and it is more relevant to monitor in patients on warfarin therapy.
Choice B rationale:
The aPTT (Activated Partial Thromboplastin Time) of 75 seconds is the correct choice as it reflects the effectiveness of unfractionated heparin therapy. Heparin works by inhibiting clotting factors in the intrinsic pathway, and the aPTT is used to monitor heparin's anticoagulant effect. The normal range for aPTT is typically 25-35 seconds.
Choice C rationale:
An INR (International Normalized Ratio) of 1.1 is not the appropriate parameter to assess the effectiveness of heparin therapy. INR is primarily used to monitor the effectiveness of oral anticoagulants like warfarin, not heparin.
Choice D rationale:
The platelet count of 200,000/mm² is not a suitable parameter to evaluate the effectiveness of heparin therapy. Platelet count is important for assessing the risk of bleeding or clotting disorders but does not directly measure the impact of heparin on clotting factors.
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