A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Tachypnea
Ketonuria
Warm skin
Nervousness
The Correct Answer is D
A. Tachypnea. Rapid breathing is associated with diabetic ketoacidosis (DKA) rather than mild hypoglycemia.
B. Ketonuria. The presence of ketones in the urine occurs with prolonged hyperglycemia and DKA, not with hypoglycemia.
C. Warm skin. Hypoglycemia typically causes cool, clammy skin due to sympathetic nervous system activation, not warmth.
D. Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
Correct Answer is C
Explanation
A. Hearing difficulties can be a challenge but do not necessarily indicate social isolation unless they lead to withdrawal from activities.
B. Babysitting twice a month still allows for social interaction and does not suggest isolation.
C. Not attending church due to a lost hearing aid suggests withdrawal from social activities, which increases the risk of social isolation.
D. Having a family member assist with grocery shopping indicates some level of social interaction and support, reducing the risk of isolation.
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