Nokea
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
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A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?
- A. Vitamin E
- B. Vitamin A
- C. Vitamin C
- D. Vitamin D
Correct Answer: C
Rationale: Vitamin C is water-soluble, requiring regular intake as it's not stored in the body.
A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed 45°
- B. Massage the client's bony prominences
- C. Provide the client with a high-calorie diet
- D. Reposition the client every 4 hrs
Correct Answer: C
Rationale: A high-calorie diet supports skin integrity and healing, reducing pressure injury risk.
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
A nurse is assisting with teaching a client who is on a low potassium diet. Which of the following instructions should the nurse include?
- A. Choose orange juice instead of apple juice.
- B. Replace sugar with molasses when baking.
- C. Eat granola for breakfast.
- D. Avoid using salt substitutes when cooking.
Correct Answer: D
Rationale: Salt substitutes contain potassium chloride, increasing potassium intake, which should be avoided.