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)
Inability to concentrate
Polydipsia
Tremors
Acetone breath odor
Diaphoresis
Correct Answer : A,C,E
Choice A reason: Inability to concentrate is a common symptom of hypoglycemia in type 1 diabetes, as low blood glucose impairs brain function, leading to confusion and difficulty focusing. This neuroglycopenic symptom results from insufficient glucose for cerebral energy, making it a critical indicator requiring prompt intervention like glucose administration.
Choice B reason: Polydipsia is associated with hyperglycemia, not hypoglycemia, in type 1 diabetes. It results from osmotic diuresis due to high blood glucose, causing dehydration and thirst. This symptom does not indicate low blood sugar, making it incorrect for identifying hypoglycemia in this scenario.
Choice C reason: Tremors are a hallmark of hypoglycemia, caused by the sympathetic nervous system’s response to low blood glucose, triggering catecholamine release. This leads to shakiness, a common adrenergic symptom, signaling the need for immediate glucose to restore normal levels, making it a correct indicator.
Choice D reason: Acetone breath odor is linked to diabetic ketoacidosis (DKA), a complication of hyperglycemia, not hypoglycemia. It results from ketone production during fat metabolism in uncontrolled diabetes. This finding is irrelevant to low blood sugar, making it incorrect for this scenario.
Choice E reason: Diaphoresis, or excessive sweating, is a classic hypoglycemia symptom due to autonomic activation from low blood glucose. The body releases adrenaline, causing sweating as a stress response. This reliable indicator prompts urgent treatment to prevent severe complications, making it a correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.
Correct Answer is D
Explanation
Choice A reason: Hyperactive deep tendon reflexes are not linked to morphine toxicity. Morphine, an opioid, depresses the central nervous system, reducing reflexes. Hyperactive reflexes suggest neurological or stimulant effects, not opioid overdose, which primarily causes respiratory and consciousness depression in affected clients.
Choice B reason: Fluid retention is not a primary sign of morphine toxicity. Morphine may cause urinary retention via sphincter tone increase, but fluid overload is unrelated. Toxicity manifests as respiratory depression or sedation, driven by mu-opioid receptor overstimulation, not fluid balance alterations.
Choice C reason: Prolonged QT interval is associated with medications like antiarrhythmics, not morphine. Morphine toxicity primarily causes respiratory depression and sedation via central nervous system effects. Cardiac effects are rare, and QT prolongation is not a hallmark of opioid overdose in clinical settings.
Choice D reason: Bradypnea indicates morphine toxicity, as opioids depress the brainstem’s respiratory center via mu-receptor overstimulation. This slows breathing, risking hypoxia and respiratory arrest, a life-threatening complication requiring immediate intervention like naloxone to reverse opioid effects and restore normal respiratory function.
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