A client arrives at the emergency department exhibiting polyuria, polydipsia, and polyphagia. Assessment findings include orthostatic hypotension, dry warm skin with decreased turgor, and acetone breath. What is the nurse's priority nursing diagnosis?
Ineffective Airway Clearance
Impaired Skin Integrity
Impaired Gas Exchange
Fluid Volume Deficit
The Correct Answer is D
Rationale:
A. There is no evidence of airway obstruction, secretion retention, or respiratory compromise in the assessment findings. Although acetone breath is present, it is a metabolic odor from ketones, not an indication of airway compromise. This diagnosis does not address the most urgent physiologic risk.
B. While dry skin and poor turgor are noted, these are symptoms of dehydration, not acute skin breakdown. Skin integrity issues are a secondary concern, not the immediate priority.
C. Although acetone breath suggests ketone accumulation, there is no evidence of hypoxia, cyanosis, or respiratory distress. The client may have compensatory Kussmaul respirations (deep, rapid breathing) due to metabolic acidosis, but gas exchange is not the primary threat at this stage.
D. The client exhibits classic signs of severe dehydration: Polyuria, polydipsia, polyphagia – signs of uncontrolled hyperglycemia (likely diabetic ketoacidosis), Orthostatic hypotension – indicates decreased intravascular volume, Dry, warm skin with poor turgor – indicates fluid loss from the extracellular compartment
Fluid replacement is the highest priority intervention, as hypovolemia can lead to shock, organ hypoperfusion, and death. Immediate IV fluids (typically isotonic saline) are essential before insulin therapy, to restore circulation and correct electrolyte imbalances safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Detemir is a long-acting insulin, typically administered once or twice daily subcutaneously. The timing (evening) is appropriate for bedtime coverage, and subcutaneous administration is correct. No clarification is needed.
B. NPH insulin is intermediate-acting and should always be administered subcutaneously, not orally. Insulin cannot be given by mouth, as it is a protein that would be digested in the GI tract and rendered inactive. This order is unsafe and requires immediate clarification with the healthcare provider.
C. Regular insulin can be administered intravenously in hospital settings for hyperglycemia or diabetic ketoacidosis. This order is appropriate for acute management of high blood glucose in type 1 diabetes.
D. Lispro is a rapid-acting insulin, administered subcutaneously before meals to manage postprandial glucose spikes. The timing and route are appropriate; no clarification is needed.
Correct Answer is C
Explanation
Rationale:
A. Clients with MS often have gait disturbances, weakness, or balance issues. Long or rapid strides increase the risk of tripping and falling. Safe ambulation requires small, deliberate steps and possibly the use of assistive devices, rather than encouraging faster movement.
B. Poor lighting increases fall risk because clients may misjudge distances or fail to see obstacles. MS patients benefit from bright, evenly distributed lighting to enhance visibility, particularly in hallways, stairs, and bathrooms. Dim lighting is unsafe.
C. Eliminating obstacles such as clutter, loose rugs, or cords reduces tripping hazards and is a primary fall-prevention strategy for clients with MS. Ensuring clear, wide pathways and secure flooring promotes safety and independence at home.
D. Assistive devices like canes, walkers, or gait belts provide stability and support, reducing fall risk. Advising a client to avoid them is unsafe and counterproductive. Proper training on device use and placement is essential for safe mobility.
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