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 B
Explanation
Choice A rationale:
(Fluticasone) Fluticasone is a corticosteroid inhaler used for the long-term management of asthma symptoms and prevention of asthma attacks. It is not suitable for treating acute asthma
attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice B rationale:
(Albuterol) Albuterol is a short-acting beta-agonist bronchodilator and the preferred medication for relieving acute asthma symptoms and treating asthma attacks. It works by quickly relaxing the airway muscles, making it easier to breathe during an asthma attack. Therefore, this is the correct choice for medications to treat an acute asthma attack.
Choice C rationale:
(Salmeterol) Salmeterol is a long-acting beta-agonist bronchodilator used for the prevention of asthma symptoms but should not be used for treating acute asthma attacks. It has a slower onset of action compared to short-acting beta-agonists like albuterol. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice D rationale:
(Beclomethasone) Beclomethasone is a corticosteroid inhaler used for long-term asthma management and prevention of asthma symptoms but is not appropriate for treating acute asthma attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
Choice B rationale:
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
Choice C rationale:
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
Choice D rationale:
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
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