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 A
Explanation
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
Correct Answer is D
Explanation
Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.
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