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. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse assess for?

Correct answer: C

Rationale: In a client with COPD, the nurse should assess for the use of accessory muscles. This is important because COPD can lead to increased work of breathing, causing the client to engage accessory muscles to help with respiration. Assessing for the use of accessory muscles provides crucial information about the client's respiratory effort. Respiratory rate (Choice A) is a standard assessment parameter but may not specifically indicate the severity of COPD. Chest pain (Choice B) is not typically associated with COPD unless there are complicating factors. Oxygen saturation (Choice D) is essential to monitor in COPD clients, but assessing for the use of accessory muscles takes priority as it directly reflects the client's respiratory status in COPD.

3. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?

Correct answer: A

Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.

4. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?

Correct answer: B

Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.

5. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?

Correct answer: D

Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.

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