a nurse is assessing a client for signs of hyperglycemia which of the following findings should the nurse look for
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Nursing Elites

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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. A healthcare professional is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?

Correct answer: C

Rationale: An increased hematocrit level indicates dehydration or fluid volume deficit. Hematocrit measures the proportion of blood volume that is occupied by red blood cells, and when a client is experiencing fluid volume deficit, there is less fluid in the blood, causing the concentration of red blood cells to be higher, leading to an increased hematocrit level. Decreased hematocrit (Choice A) is more indicative of fluid volume excess. Increased BUN (Choice B) is associated with renal function and dehydration but is not a direct indicator of FVD. Decreased urine specific gravity (Choice D) is also associated with dehydration, but an increased hematocrit is a more specific indicator of fluid volume deficit.

3. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?

Correct answer: B

Rationale: A positive Kernig’s sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding indicates meningeal irritation. Choices A, C, and D do not describe Kernig’s sign. Choice A describes a normal plantar reflex, choice C refers to coordination issues, and choice D describes neck pain and stiffness, which are not specific to Kernig’s sign.

4. A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?

Correct answer: D

Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.

5. A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Correct answer: A

Rationale: The correct answer is A: “I can expect swelling in my hands and on my face.” Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.

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