A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
Irritability
Increased urination
Vomiting
Facial flushing
The Correct Answer is A
Irritability.
The rationale for each choice is as follows:
- A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
- B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
- C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
- D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
- b. The client's most recent ventilator settings:The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
- c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.
d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.
Correct Answer is D
Explanation
Initiate transmission-based precautions.
Rationale:
- B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
- A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.
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