Nokea
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Thirst indicates hyperglycemia as the body attempts to excrete excess glucose, causing dehydration.
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A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?
- A. Inflammation
- B. Remodeling phase
- C. Maturation
- D. Proliferation
Correct Answer: A
Rationale: Inflammation is the first phase of wound healing, initiating hemostasis and infection prevention.
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia, especially aspiration pneumonia, is a major risk in dysphagia due to potential inhalation of food or liquids.
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.