A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)
Tachycardia
Polydipsia
Polyuria
Blurred vision
Moist, clammy
Correct Answer : A,D,E
A. Tachycardia, or increased heart rate, can occur during hypoglycemia as a result of the body's response to low blood sugar levels. The sympathetic nervous system is activated, leading to increased adrenaline (epinephrine) release, which can cause palpitations and tachycardia.
B. Polydipsia refers to excessive thirst. It is typically a symptom of hyperglycemia (high blood sugar levels) rather than hypoglycemia. During hypoglycemia, thirst is not a common symptom.
C. Polyuria refers to excessive urination. Similar to polydipsia, it is more commonly associated with hyperglycemia (high blood sugar levels) rather than hypoglycemia. Hypoglycemia typically does not cause polyuria.
D. Blurred vision can occur during hypoglycemia due to changes in the shape of the lens in the eye caused by altered fluid balance due to low blood sugar levels.
E. Moist, clammy skin is a common manifestation of hypoglycemia. When blood sugar levels drop, the body's autonomic nervous system responds by releasing adrenaline, which can cause sweating and clamminess.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Catheter irrigation involves flushing the catheter with a sterile solution to clear any obstruction within the tubing or catheter itself. It can help in cases where there might be clots obstructing urine flow. However, irrigating the catheter is an intervention that requires proper assessment and order from the healthcare provider.
B. This option suggests adjusting the rate of the bladder irrigant, which typically refers to the irrigation solution used during the TURP procedure to maintain catheter patency and prevent clot formation. However, this action requires assessment of the situation and potential orders from the provider.
C. Notifying the provider is often the first action the nurse should take when encountering a significant change in the client's condition or a potential complication, such as a blocked catheter. The provider needs to be informed so they can assess the situation, provide further orders, and decide on the appropriate course of action to manage the urinary retention effectively.
D. Checking the tubing for kinks or other external obstructions is a prudent initial action. Kinks or twists in the catheter tubing can prevent urine from draining properly. If a kink is identified, it can be corrected immediately, allowing urine to flow freely again.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
The client reports symptoms of vomiting and diarrhea for the past 12 hours. These symptoms are classic indicators of fluid loss from the gastrointestinal tract. Vomiting and diarrhea lead to significant fluid depletion, resulting in a fluid volume deficit. This deficit can lead to dehydration, electrolyte imbalances, and potentially hypotension (low blood pressure), which are consistent with the client's clinical presentation of tachycardia (increased heart rate) and hypotension (blood pressure 102/58 mmHg). The plan for IV fluid replacement upon admission reflects the need to address and correct this fluid deficit.
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