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A nurse is caring for a client who has type 2 diabetes mellitus and notes the client is declining. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?

Hypertension

Fruity breath

Ketosis

Glucose level of 650 mg/dL

Answer and Explanation

The Correct Answer is D

A. Hypertension can be a symptom of many conditions and is not specific to HHS.

B. Fruity breath is typically associated with diabetic ketoacidosis (DKA) due to the presence of acetone, not HHS.

C. Ketosis is a key feature of DKA, not HHS. In HHS, ketosis is usually absent or minimal.

D. A glucose level of 650 mg/dL is indicative of HHS, which is characterized by extremely high blood glucose levels without significant ketosis. HHS often occurs in type

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Correct Answer is D

Explanation

A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.

B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.

C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.

D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.

A. Airway patency B. Temperature C. Pain control D. Urination

Correct Answer is A

Explanation

A. Airway patency is the highest priority following a thyroidectomy due to the risk of airway obstruction from swelling or hematoma formation near the surgical site. Compromised airway can lead to respiratory distress and requires immediate attention.

B. While monitoring temperature is important for detecting potential infections, it is not the immediate priority.

C. Pain control is important for comfort and recovery, but it is not life-threatening.

D. Urination should be monitored postoperatively, but it is not as critical as ensuring a patent airway.

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A nurse is caring for a client who has type 2 diabetes mellitus and notes the client is declining. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is A

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A nurse is caring for a client who has type 2 diabetes mellitus and notes the client is declining. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?