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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

A. An infant who has respiratory syncytial virus B. A child who has bacterial meningitis C. An infant who has hypertrophic pyloric stenosis D. A child who has Kawasaki disease

Correct Answer is B

Explanation

A. An infant who has respiratory syncytial virus (RSV) primarily experiences respiratory symptoms such as wheezing, coughing, and difficulty breathing. RSV does not typically cause seizures.
B. A child who has bacterial meningitis is at high risk for seizures due to increased intracranial pressure, cerebral irritation, and inflammation. Seizure precautions, including padded side rails, oxygen, and suction at the bedside, should be initiated.
C. An infant who has hypertrophic pyloric stenosis experiences projectile vomiting and dehydration but is not at risk for seizures.
D. A child who has Kawasaki disease is at risk for coronary artery complications, but seizures are not a common complication of this condition.

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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?

Nursing Test Bank

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