A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

Acetone breath odor

Polydipsia

Inability to concentrate

Diaphoresis

Tremors

Answer and Explanation

Correct Answer : C,D,E

Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.

B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.

C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.

D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.

E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.

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

Explanation

Rationale for Correct Choices

• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.

• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.

Rationale for Incorrect Choices

• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.

• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.

• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.

A. 0.45% sodium chloride B. Lactated Ringer's C. 0.9% sodium chloride D. 3% sodium chloride

Correct Answer is A

Explanation

Rationale:
A. 0.45% sodium chloride: This is a hypotonic solution that helps lower elevated serum sodium levels by promoting water movement into the intracellular space. It is appropriate for correcting hypernatremia gradually while preventing cerebral edema.

B. Lactated Ringer's: Lactated Ringer’s is an isotonic solution containing sodium, potassium, and calcium. It is not ideal for hypernatremia because its sodium content can maintain or worsen elevated serum sodium levels.

C. 0.9% sodium chloride: Normal saline is isotonic and contains a high concentration of sodium, which would not reduce hypernatremia and could exacerbate the condition if used for correction.

D. 3% sodium chloride: This hypertonic solution increases serum sodium levels and is used to treat hyponatremia, not hypernatremia. Administering it to a client with hypernatremia would worsen the electrolyte imbalance.

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A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

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