Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?
Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes.
Alert and oriented, balanced intake and output, moist mucous membranes.
Respirations easy and unlabored, eats 50-75% of meals, vital signs stable.
Equal intake and output, denies pain or shortness of breath.
The Correct Answer is A
A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.
B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.
C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.
D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.
B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.
C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.
D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.
Correct Answer is B
Explanation
A. Labeling the mother as "overprotective" is dismissive and non-therapeutic.
B. This response uses therapeutic communication to explore the mother’s concerns without judgment, allowing for education and support.
C. Suggesting home-schooling may reinforce unnecessary restrictions and does not address the concern.
D. Agreeing outright does not help the mother understand that physical activity can be managed safely.
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