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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The excoriated and red skin in the diaper area suggests the presence of diaper dermatitis, which is commonly caused by prolonged exposure to moisture and irritants such as urine and feces. Changing the diaper more frequently helps to minimize the exposure to these irritants and promotes better skin hygiene.
Asking the mother to decrease the infant's intake of fruits for 24 hours is not necessary unless there is evidence of diarrhea or specific dietary concerns. Fruits are generally a healthy part of an infant's diet and do not directly cause diaper dermatitis.
Encouraging the mother to apply lotion with each diaper change may not be recommended in this case, as lotions and creams can further trap moisture and exacerbate the condition. It is best to keep the area clean and dry.
Telling the mother to cleanse with soap and water at each diaper change may be too harsh for the infant's sensitive skin. Plain water or mild, fragrance-free wipes are typically sufficient for cleaning the diaper area. Soap can be drying and irritating to the skin, so it is generally not necessary unless there is a specific indication.
Correct Answer is D
Explanation
Acute kidney injury (AKI) can have significant impacts on the client's fluid and electrolyte balance. Mannitol, a diuretic, is commonly used to promote diuresis and increase urine
output in cases of AKI. However, it is essential to assess the client's hemodynamic status and overall condition before administering mannitol.
Obtaining vital signs (such as blood pressure, heart rate, respiratory rate, and temperature) helps evaluate the client's baseline status and monitor for any changes that may occur after administering mannitol. It is particularly important to assess blood pressure as mannitol can potentially cause hypotension as a side effect.
Assessing breath sounds is also crucial because pulmonary edema can occur as a complication of AKI. Mannitol administration may exacerbate this condition. Therefore, assessing breath sounds allows the nurse to monitor for signs of fluid overload, such as crackles or wheezes.
Collecting a clean catch urine specimen may be necessary for diagnostic purposes to assess kidney function and determine the presence or severity of acute kidney injury. However, obtaining vital signs and assessing breath sounds should be the first nursing intervention before administering any medication, including mannitol, to ensure the client's safety and monitor for any potential adverse effects.
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