A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus.
The nurse determines that teaching has been effective when the client identifies
which of the following manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry vision
3) Tachycardia
INCORRECT
4) Polydipsia
5) Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision,
tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors, anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors, anxiety, irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
INCORRECT
5) Symmetrical joint pain
Answer Rationale:
,Edema is correct. Swelling over the affected joints is a classic manifestation of
gout.
Erythema is correct. Redness over the affected joints is a classic manifestation
of gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules
that form in subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic
manifestation of gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation
of rheumatoid arthritis, not gout.
7. A nurse is assisting in the plan of care for a client who had surgery for a
bowel obstruction. The client has a nasogastric tube in place. Which of the
following actions should the nurse include in the client's plan of care? (Select all
that apply.)
1) Perform leg exercises every 2 hr.
2) Encourage hourly use of an incentive spirometer while awake.
3) Document the color, consistency, and amount of nasogastric drainage.
INCORRECT
4) Irrigate the nasogastric tube every 4 to 8 hr.
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