A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Kussmaul respirations

Diaphoresis

Decreased skin turgor

Ketonuria

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.

Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Unilateral weakness is an incorrect finding, because it is more indicative of a stroke or a brain tumor than encephalitis. Encephalitis is an inflammation of the brain that can cause neurological symptoms, but they are usually bilateral and symmetrical.

Choice B reason: Stiff neck is a correct finding, because it is a sign of meningeal irritation, which can occur in encephalitis due to the involvement of the meninges (the membranes that cover the brain and spinal cord).

Choice C reason: Photophobia is a correct finding, because it is another sign of meningeal irritation, which can cause sensitivity to light and sound.

Choice D reason: Epigastric pain is an incorrect finding, because it is not related to encephalitis. Epigastric pain is more likely to be caused by a gastrointestinal disorder, such as gastritis or peptic ulcer.

Choice E reason: Lethargy is a correct finding, because it is a sign of altered mental status, which can occur in encephalitis due to the damage to the brain tissue.

A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Wearing a gown is a correct action, because it protects the nurse's clothing and skin from exposure to the client's body fluids.

Choice B reason: Wearing gloves is a correct action, because it protects the nurse's hands from contact with the client's body fluids and reduces the risk of transmission of HIV.

Choice C reason: Wearing a mask is a correct action, because it protects the nurse's mouth and nose from exposure to the client's respiratory secretions and reduces the risk of airborne infections.

Choice D reason: Wearing a hair cover is an incorrect action, because it is not necessary for standard precautions or contact precautions, which are the types of isolation required for a client who has AIDS and is incontinent of stool.

Choice E reason: Wearing goggles is a correct action, because it protects the nurse's eyes from exposure to the client's body fluids and reduces the risk of mucous membrane infections.

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A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Nursing Test Bank

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