During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.
I sleep at least 8 hours each night.
I cannot seem to quench my thirst.
I have to void nearly every hour.
At times my vision is blurry.
I have lost 10 pounds without even trying.
Correct Answer : B
Choice A Reason:
I sleep at least 8 hours each night.
This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.
Choice B Reason:
I cannot seem to quench my thirst.
This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.
Choice C Reason:
I have to void nearly every hour.
Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.
Choice D Reason:
At times my vision is blurry.
Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.
Choice E Reason:
I have lost 10 pounds without even trying.
Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is J
Explanation
Choice A Reason:
Gaining weight can be an indicator of improved nutrition, but it does not directly address the client’s ability to swallow safely and effectively. Weight gain could be due to other factors such as fluid retention or changes in metabolism. Therefore, while it is a positive outcome, it is not the best indicator of improved swallowing function.
Choice B Reason:
Choosing preferred items from the menu indicates that the client is engaged in their meal planning and has an appetite. However, it does not directly measure the client’s ability to swallow safely. The client might still have difficulty swallowing even if they are choosing their preferred foods.
Choice C Reason:
Clear understanding and articulation are important for communication and can indicate cognitive improvement. However, this choice does not directly relate to the client’s swallowing ability. The primary concern in this scenario is the client’s ability to swallow safely, not their communication skills.
Choice D Reason:
Eating 75 to 100% of all meals and snacks is the best indicator that the client has improved their swallowing ability. This choice directly measures the client’s ability to consume food and liquids safely and effectively. It shows that the client can manage their meals without significant difficulty, which is the primary goal of the intervention.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: A 22-year-old client with asthma is considered a priority for pneumonia vaccination. Asthma is a chronic respiratory condition that can increase the risk of complications from pneumonia. Vaccination helps protect against pneumococcal infections, which can be particularly severe in individuals with underlying respiratory conditions.
Choice B reason: A healthy 72-year-old client is also a priority for pneumonia vaccination. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for all adults aged 65 years and older. Older adults are at higher risk for pneumococcal disease due to age-related decline in immune function.
Choice C reason: A client with well-controlled diabetes should be prioritized for pneumonia vaccination. Diabetes can weaken the immune system, making individuals more susceptible to infections, including pneumonia. Vaccination is an important preventive measure for individuals with chronic health conditions.
Choice D reason: A client who is taking medication for hypertension is not necessarily a priority for pneumonia vaccination based solely on their hypertension. While hypertension is a common condition, it does not directly increase the risk of pneumococcal disease. However, if the client has other risk factors or comorbidities, they may still be considered for vaccination.
Choice E reason: A client who had a cholecystectomy last year is not a priority for pneumonia vaccination based on this surgical history alone. A cholecystectomy, which is the removal of the gallbladder, does not increase the risk of pneumococcal disease. Priority for vaccination is typically given to individuals with chronic health conditions, older adults, and those with weakened immune systems.
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