A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?
Fever.
Shakiness.
Increased urination.
Thirst.
The Correct Answer is B
Choice A rationale:
Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.
Choice B rationale:
Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.
Choice C rationale:
Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.
Choice D rationale:
Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common indicator of unrelieved pain in a client. It suggests that the client is uncomfortable and experiencing discomfort, which could be due to inadequate pain relief. Restlessness may manifest as frequent shifting, fidgeting, and an inability to find a comfortable position. Therefore, choice A is the correct answer as it is a reliable indicator of unrelieved pain.
Choice B rationale:
Urinary retention is not typically associated with unrelieved pain in a client with a spinal epidural for a herniated disc. Urinary retention may result from the effects of the epidural anesthesia itself but is not a specific indicator of unrelieved pain. Therefore, choice B is not the correct answer.
Choice C rationale:
Constipation is not a direct indicator of unrelieved pain related to a spinal epidural. Constipation can occur for various reasons, including medications, decreased mobility, and dietary factors. While pain may contribute to constipation indirectly, it is not a reliable and specific sign of unrelieved pain in this context. Therefore, choice C is not the correct answer.
Choice D rationale:
Difficulty swallowing is not typically associated with unrelieved pain related to a spinal epidural. It may be related to other factors, such as muscle weakness or neurological issues, but it is not a specific indicator of unrelieved pain in this situation. Therefore, choice D is not the correct answer.
Correct Answer is B
Explanation
Choice A rationale:
A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.
Choice B rationale:
The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.
Choice C rationale:
Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.
Choice D rationale:
The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.
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