a nurse is assessing a client for signs of hyperglycemia which of the following findings should the nurse look for
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PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?

Correct answer: A

Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.

2. Before an amniocentesis, what action by the client will need to be completed?

Correct answer: B

Rationale: Before an amniocentesis, the client should empty their bladder. This is necessary to reduce the risk of bladder puncture during the procedure. A full bladder can be in the path of the needle, increasing the risk of injury. Increasing fluid intake (choice A) is not necessary before an amniocentesis. Avoiding eating for 12 hours (choice C) is not a standard preparation for an amniocentesis. Taking a sedative (choice D) is not routinely required for this procedure.

3. A nurse is sitting with the partner of a client who recently died. Which of the following actions should the nurse take to facilitate mourning?

Correct answer: A

Rationale: The correct action for the nurse to take to facilitate mourning is to encourage the partner to ask for help when needed. Grieving is a challenging process, and offering support and encouragement to seek help can be beneficial. Choice B is incorrect because avoiding discussing feelings can hinder the grieving process by suppressing emotions. Choice C is also incorrect as an immediate return to daily activities may not allow the partner to properly process their grief. Choice D is not the best approach as advising the partner to 'remain strong' may discourage the expression of emotions and seeking support, which are essential in the mourning process.

4. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

Correct answer: C

Rationale: The correct action for the nurse to take before performing a closed intermittent bladder irrigation is to apply sterile gloves. Sterile gloves help maintain asepsis, reduce the risk of infection, and ensure patient safety during the procedure. Aspirating the irrigation solution from the bladder (Choice A) is not a standard step in closed intermittent bladder irrigation. Inserting the tip of the irrigation syringe into the catheter opening (Choice B) can introduce contaminants into the system. Opening the flow clamp to the irrigating fluid infusion tubing (Choice D) should only be done after ensuring all equipment is ready and the nurse is gloved to maintain sterility.

5. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

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