A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

"Sweating can occur with hypoglycemia."

"My son might complain of feeling shaky when he has a low blood glucose level."

"My son might have nausea and vomiting with hypoglycemia."

"The onset of low blood glucose usually occurs rapidly."

Answer and Explanation

The Correct Answer is C

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.

D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.

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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.

A. Reposition the client every 2 hr. B. Elevate the head of the client's bed 45° C. Massage the client's bony prominences. D. Provide the client with a high-calorie diet.

Correct Answer is A

Explanation

A. Reposition the client every 2hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.

B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.

C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.

D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.

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A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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