A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
Absence of Chvostek's sign
Presence of Kussmaul respirations
Presence of diaphoresis
Absence of urinary ketones
The Correct Answer is B
Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial muscles in response to tapping the facial nerve and is typically associated with low blood calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis (DKA), a severe complication of diabetes characterized by significantly high blood sugar levels and the presence of ketones in the blood and urine. This type of breathing pattern is the body's attempt to compensate for the acidic state caused by high blood sugar and the buildup of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating, which can occur due to various reasons such as physical activity, heat, stress, or certain medical conditions. While hyperglycemia can cause symptoms like increased thirst and frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates the body is breaking down fat for energy, which commonly occurs during periods of insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia to be present without ketones in the urine, especially in the early stages or when the body is still managing blood sugar levels without significant ketone production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Chill the dialysate prior to infusion. Generally, the dialysate used in peritoneal dialysis is warmed to body temperature before infusion to enhance comfort and prevent abdominal discomfort. Chilling the dialysate can cause discomfort and is not a standard practice in peritoneal dialysis.
Choice B Reason:
Monitor the client for diarrhea. While gastrointestinal symptoms might occur in some individuals undergoing peritoneal dialysis due to changes in fluid balance, diarrhea is not a typical or expected outcome. However, monitoring for any unusual gastrointestinal symptoms or changes in bowel habits is part of holistic client care.
Choice C Reason:
Weigh the client before and after the treatment. Weighing the client before and after peritoneal dialysis is a critical step to assess the effectiveness of the treatment. The difference in weight helps determine how much fluid was removed during the dialysis process, providing valuable information about the treatment's efficacy and the client's fluid status.
Choice D Reason:
Use clean gloves when handling dialysate bags. Maintaining aseptic technique during peritoneal dialysis is crucial to prevent infections. The use of clean gloves (not sterile gloves, unless otherwise specified) when handling dialysate bags helps minimize the risk of contamination, ensuring the safety of the procedure.
Correct Answer is B
Explanation
Choice A Reason:
Requesting a dosage increase if the apical heart rate is less than 60/min is not necessary. Propranolol is used to lower heart rate in conditions like atrial fibrillation, so a heart rate below 60/min might be the desired effect of the medication.
Choice B Reason:
Withholding the medication if the systolic blood pressure is less than 90 mm Hg is necessary. Propranolol is a beta-blocker that can lower blood pressure. If the systolic blood pressure drops below 90 mm Hg, withholding the medication is necessary to prevent further lowering of blood pressure, which could lead to adverse effects like dizziness, fainting, or inadequate blood perfusion to vital organs.
Choice C Reason:
Administering the medication with an antacid might interfere with the absorption of propranolol, so they shouldn't be taken together unless instructed by the healthcare provider.
Choice D Reason:
Expecting increased hair growth is not an anticipated effect of propranolol. Hair growth is not a usual side effect associated with this medication.
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