43. On her first postpartum day, a woman who is diabetic has been eating a full diet, and her insulin was reduced to one third of the dosage received during pregnancy. Which sign(s) and/or symptom(s) would indicate that the client is experiencing hyperglycemia? Select all that apply.
. Profuse perspiration.
. Irritability.
. Flushed face.
. Headache.
. Rapid pulse.
. Deep, rapid respirations.
Test-Taking Tip
Think about the expected changes with sufficient or insufficient glucose levels. Review signs and symptoms of hypoglycemia and hyperglycemia.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because profuse perspiration or diaphoresis is associated with an insulin reaction or a low blood sugar. Answer 2 is correct because irritability, confusion, and lethargy are associated with high blood sugar levels. Answer 3 is correct because flushing is associated with dehydration, which results from a high blood sugar level. Answer 4 is correct because headache can result from high or low blood sugar levels. Answer 5 is correct because hyperglycemia can lead to hypovolemic shock, with a rapid, thready pulse from severe dehydration. Answer 6 is correct because deep, rapid breathing (Kussmaul's breathing) is an attempt to compensate for the increased carbon dioxide level resulting from ketoacidosis.