A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client's hands. based on the client's history and the nurse's understanding of diabetes mellitus, the nurse interprets these findings to be signs of:

Correct Answer: D

Rationale: The signs of irritability, irrational behavior, and visible tremors in the hands observed in the 45-year old female diabetic suggest hypoglycemia. Hypoglycemia occurs when blood sugar levels drop below normal levels, causing the body and brain to receive inadequate fuel. This leads to symptoms like irritability, irrational behavior, and tremors, which are signs of the brain not receiving enough glucose for proper functioning. In diabetic patients, particularly those on medications like insulin or certain oral hypoglycemic agents, hypoglycemia can occur if they take too much medication, skip meals, or engage in excessive physical activity without adjusting their treatment regimen. Immediate treatment for hypoglycemia usually involves consuming a rapid source of sugar, such as glucose tablets, juice, or candy, to quickly raise blood sugar levels back to normal range.

Correct Answer: C

Rationale: Following a subtotal thyroidectomy, there is a risk of airway compromise and difficulty breathing due to the close proximity of the surgical site to the trachea. In case of swelling or other complications leading to airway obstruction, having a tracheostomy set readily available at the client's bedside is crucial for quick and efficient management of any respiratory distress. This equipment allows the healthcare team to establish a secure airway if needed, ensuring the client's safety and minimizing the risk of respiratory compromise post-operatively. The other equipment choices are important but having a tracheostomy set is the most critical for this particular situation to address potential airway issues promptly.

Correct Answer: C

Rationale: Antibodies, also known as immunoglobulins, are proteins produced by a type of white blood cell called B-lymphocytes (B-cells). These antibodies play a crucial role in the immune response by recognizing and binding to specific antigens such as pathogens. This binding can lead to the inactivation of the pathogens or marking them for destruction by other immune cells. B-cells are a key component of the humoral immune response, which involves the production of antibodies to defend against infections. The statement that antibodies are produced by the B-cells is, therefore, true.

Correct Answer: B

Rationale: When caring for Mr. Reyes, the nurse should assess for an altered level of consciousness as it is a crucial indicator of his overall neurological status. Changes in consciousness can signify multiple underlying issues such as neurological, metabolic, or circulatory problems. It is important for the nurse to monitor Mr. Reyes closely for any signs of confusion, disorientation, agitation, drowsiness, or changes in behavior that could indicate a decline in his neurological function. Assessing and addressing alterations in consciousness promptly is essential for providing appropriate care and preventing further complications.

Correct Answer: B

Rationale: Option B, "I told her she is wrong and I explained to her what is right," would require the nurse to give further teaching because it indicates a lack of understanding about how to communicate with a person experiencing hallucinations. People with hallucinations may have a distorted sense of reality, and arguing with them or insisting on what is "right" can be counterproductive. The daughter would benefit from additional education on how to effectively communicate and support her father during episodes of hallucinations.