A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
Report of decreased urinary output
Random blood glucose 126 mg/dL
Clammy skin
History of poor wound healing
The Correct Answer is D
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.
B. Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.
C. Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.
D. Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.
E. Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.
Correct Answer is C
Explanation
A. Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.
B. Avoids using the fingers of her dominant hand as puncture sites:While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.
C. Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.
D. Avoids using the thumbs as puncture sites:
Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.
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