Patient Data

Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"

Which are the nurse's best responses? Select all that apply.

"Hyperglycemia often results in weight loss."

"Hyperglycemia causes cool and clammy skin."

"Hyperglycemia causes an increased sensation of being hungry."

"Hyperglycemia causes a headache and flushed, dry skin."

"Hyperglycemia often presents as increased thirst and urination."

Answer and Explanation

Correct Answer : D,E

A. "Hyperglycemia often results in weight loss.": Weight loss is more commonly associated with prolonged hyperglycemia, particularly in uncontrolled diabetes where the body starts breaking down fat and muscle for energy.

B. "Hyperglycemia causes cool and clammy skin.": Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia.

C. "Hyperglycemia causes an increased sensation of being hungry.": Increased hunger is often associated with hypoglycemia or uncontrolled diabetes, where insulin is not effectively managing blood glucose levels.

D. "Hyperglycemia causes a headache and flushed, dry skin.": In cases of significant hyperglycemia, symptoms can include headache and flushed, dry skin due to dehydration. These symptoms arise from the body’s attempt to balance blood sugar levels and manage dehydration.

E. "Hyperglycemia often presents as increased thirst and urination.": Hyperglycemia typically leads to increased thirst (polydipsia) and increased urination (polyuria). This occurs because the body tries to get rid of excess glucose through the urine, leading to dehydration and increased thirst.

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Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Peripheral pulses present with full range of motion of both legs. B. History of vomiting at home for 3 days prior to surgery. C. Soft abdomen, absent bowel sounds, no bleeding on dressing. D. Declining to take ice chips despite reporting of dry mouth.

Correct Answer is C

Explanation

A. While the presence of peripheral pulses and full range of motion is important, it is typically included in the physical assessment findings and is less immediately relevant to postoperative status compared to other options.

B. The history of vomiting at home is part of the client’s medical history but is not immediately relevant to the postoperative status.

C. Information about the abdomen (soft, absent bowel sounds, no bleeding on dressing) is critical as it pertains directly to the surgical site and postoperative recovery.

D. Declining ice chips despite reporting a dry mouth is noteworthy but less critical than assessing the surgical site and abdominal status.

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Patient Data Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

Nursing Test Bank

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Correct Answer is B

Explanation

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Patient Data

Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"

Which are the nurse's best responses? Select all that apply.