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 ["25"]
Explanation
The prescription is for 1 gram of azithromycin, which is 1000 mg. The concentration of
the suspension is 200 mg per 5 mL. To calculate the amount in mL:
1000 mg / 200 mg per 5 mL = 25 mL
The nurse should administer 25 mL of the suspension.
Correct Answer is B
Explanation
A.Protect the site from getting wet during bathing. While it is important to avoid prolonged soaking, gentle rinsing with water is usually allowed. Complete avoidance of water is not typically necessary.Gentle bathing is important for hygiene.
B.Gently patting the skin dry after rinsing with water is a good practice as it helps to minimize friction and irritation to the sensitive skin. Rubbing or scrubbing the skin should be avoided.
C. Applying moisturizers to prevent dry skin can be beneficial for overall skin health, but it is important to consult with the healthcare team and follow specific instructions regarding the use of moisturizers during radiation therapy. Certain types of moisturizers or creams may interfere with the radiation treatment or cause skin irritation. Frequent application is not always necessary. Over-hydration can soften the skin and increase vulnerability.
D.Using a sponge to debride the affected area is not recommended during radiation therapy. The skin in the radiation treatment field is already sensitive and prone to damage, and using a sponge for debridement can further traumatize the skin. It is important to avoid any abrasive or rough handling of the treated skin.
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