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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

"I can take my partner outside of the room as long as they wear a mask."MRSA contact precautions typically involve limiting the spread of the bacteria. Taking the partner outside the room while wearing a mask might not be sufficient for infection control, as MRSA can spread through direct contact with surfaces. This statement might not indicate a full understanding of MRSA precautions.

Choice B Reason:

"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of infection control for MRSA. Washing hands with soap and water or using alcohol-based hand sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.

Choice C Reason:

"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that might involve contact with the patient's bodily fluids or surfaces that might be contaminated is recommended for MRSA precautions. This statement aligns with infection control practices.

Choice D Reason:

"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves should be disposed of after each use and hands washed thoroughly.

A. “Twill increase vitamin C intake by drinking orange juice." B. “will eat six small meals each day." C. "I will lie down for 30 minutes after each meal." D. “will sleep flat on my back at night."

Correct Answer is B

Explanation

Choice A Reason:

“Twill increase vitamin C intake by drinking orange juice." Reason why it might not indicate an understanding: Citrus juices like orange juice can exacerbate GERD symptoms due to their acidity. Increasing intake might worsen reflux symptoms for many individuals with GERD.

Choice B Reason:

“Will eat six small meals each day." This statement indicates an understanding. Eating smaller, more frequent meals instead of three large meals can help reduce pressure on the lower esophageal sphincter (LES), minimizing the likelihood of stomach contents flowing back into the esophagus, which commonly triggers GERD symptoms.

Choice C Reason:

"I will lie down for 30 minutes after each meal." Reason why it might not indicate an understanding: Lying down after meals can worsen GERD symptoms. Remaining upright or at least sitting upright for a few hours after meals helps prevent reflux by allowing gravity to assist in keeping stomach contents from moving up into the esophagus.

Choice D Reason:

“Will sleep flat on my back at night." Reason why it might not indicate an understanding: Sleeping flat on the back can aggravate GERD symptoms as it allows stomach acid to flow more easily into the esophagus. Sleeping with the head elevated (using pillows or an adjustable bed) is recommended to reduce nighttime reflux.

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A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

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