A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

Kussmaul respirations

Increased urine output

Cool, clammy skin

Acetone breath

Answer and Explanation

The Correct Answer is C

C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.

A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.

B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.

D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.

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Correct Answer is C

Explanation

C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.

A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.

B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.

D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).

A. "Did you decrease your insulin intake before you exercised?" B. "It is normal to feel this way after a morning run." C. "Were you careful to not have carbohydrates after the run?" D. "It becomes easier when exercise is a routine."

Correct Answer is A

Explanation

A This response addresses a potential cause of exercise-induced hypoglycemia. Clients with type 1 diabetes often need to adjust their insulin dose or carbohydrate intake before exercise to prevent hypoglycemia. Asking about insulin adjustment is relevant to assess whether the client took appropriate precautions.

B. While exercise can cause fatigue, feeling diaphoretic, having palpitations, and extreme exhaustion are not normal responses after exercise, especially for someone with type 1 diabetes. This response does not address the potential cause of the symptoms.

C. This response addresses the importance of carbohydrate intake post-exercise to prevent or treat hypoglycemia. It encourages the client to reflect on their dietary choices following exercise, which can impact blood glucose levels.

D. While establishing a routine for exercise is beneficial for managing diabetes, this response does not address the immediate concern of hypoglycemia or provide guidance on managing the client's current symptoms.

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A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

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A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

Correct Answer is C

Explanation

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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