The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

Blood pressure 130/80 mm Hg.

Cervical spine stiffness.

Dark yellow urine.

Excessive perspiration.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- A blood pressure of 130/80 mm Hg is within a generally acceptable range for a person with diabetes and coronary artery disease. It may not directly indicate a complication related to the episodes of confusion. While blood pressure management is important for clients with diabetes and coronary artery disease, this particular blood pressure reading is not necessarily a significant finding in relation to the client's confusion.
B)   Correct- Cervical spine stiffness or neck stiffness is a potential neurological symptom that can indicate a serious complication in a client with type 2 diabetes and coronary artery disease. The stiffness of the neck may be a sign of meningeal irritation, which can result from various conditions including infections such as meningitis. The client's medical history includes both type 2 diabetes and coronary artery disease, which are risk factors for cardiovascular events, including cerebrovascular accidents (strokes). Confusion can be a symptom of a stroke, and neck stiffness can be indicative of meningeal irritation secondary to a stroke or another neurological condition.
C)   Incorrect- Dark yellow urine can be a sign of dehydration, which can be a concern for someone with diabetes. However, it is not directly related to episodes of confusion. Dehydration can cause various symptoms, but confusion is not typically associated with mild dehydration.
D)   Incorrect- Excessive perspiration (diaphoresis) can occur for various reasons, including increased sympathetic nervous system activity, fever, anxiety, and physical activity. While it can be a symptom of certain complications, such as hypoglycemia (low blood sugar) or heart attack, it alone may not directly relate to the episodes of confusion in this client.

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Correct Answer is ["A","C","D"]

Explanation

A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.

A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

Correct Answer is D

Explanation

A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

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The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Correct Answer is D

Explanation

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