A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
Diminished reflexes
Rapid respirations
Acetone breath
Headache
The Correct Answer is D
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.
B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.
C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.
D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.
Correct Answer is C
Explanation
A. Height of the IV pole:
Explanation: The height of the IV pole is important for controlling the rate of the TPN infusion. Adjusting the height can regulate the flow rate.
B. IV insertion site:
Explanation: Monitoring the IV insertion site is crucial to assess for signs of infection, inflammation, or infiltration, which can compromise the effectiveness of TPN.
C. Manifestations of hypoglycemia:
Explanation: TPN often contains glucose, and monitoring for signs of hypoglycemia is important, as abrupt cessation of TPN can lead to low blood glucose levels.
D. The client's oral intake:
Explanation: Since the client is receiving TPN, their oral intake is not the primary source of nutrition. TPN provides essential nutrients intravenously.
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