A client with type 1 diabetes is admitted to the emergency department for DKA. Which assessment findings should the nurse expect to note?
Fruity breath odor and increased respiratory rate.
Hunger and hypertension
Cold, clammy skin and irritability
Sweating and tremors
The Correct Answer is A
A. DKA is characterized by the production of ketones, which can lead to a fruity or acetone-like odor on the breath. Additionally, the increased respiratory rate (Kussmaul breathing) occurs as the body attempts to compensate for metabolic acidosis by blowing off carbon dioxide.
B. While clients with diabetes may experience hunger, it is not a primary symptom of DKA. Hypotension (rather than hypertension) is more commonly observed due to dehydration and fluid loss associated with DKA.
C. Cold, clammy skin suggests the body is in a sympathetic state due to low blood sugar. While irritability can occur in various situations, it is not a hallmark sign of DKA.
D. Sweating and tremors are symptoms of low blood sugar levels and are not characteristic of DKA. In DKA, patients typically present with dry skin due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A fracture involving the epiphyseal plate (growth plate) can lead to differential growth in the affected limb. If a fracture occurs before the growth plate has closed, it can potentially result in the shorter leg as the growth in that limb may be inhibited compared to the unaffected leg.
B. While scoliosis can lead to asymmetrical body positioning and potentially cause a perception of leg length discrepancy, it does not typically cause a true difference in bone length. Instead, scoliosis affects the spine's curvature and may alter posture, but it’s not a direct cause of one leg being shorter than the
other.
C. A comminuted clavicle fracture primarily affects the shoulder and does not impact leg length. It involves the upper limb and does not contribute to any differences in the lengths of the legs, making this option irrelevant to the observed leg length discrepancy.
D. JIA can lead to joint inflammation and may affect limb growth if it causes significant damage to the joints. However, while it can potentially cause some discrepancies in limb length due to joint issues, it is less directly associated with one leg being shorter than the other compared to an epiphyseal plate fracture.
Correct Answer is D
Explanation
A. While changes in breathing patterns can indicate airway obstruction, snoring alone is not the most specific indicator of a complication after tonsillectomy. It could indicate swelling or an obstructed airway but does not specifically indicate bleeding.
B. Checking the mucous membranes for moisture is important in general nursing care to assess hydration status. However, it is not the most immediate priority in the post-tonsillectomy setting, where the primary concern is to monitor for bleeding.
C. Assessing pain is important for overall patient comfort and to evaluate the effectiveness of pain management strategies. However, pain alone does not directly indicate a complication like bleeding, which is a critical concern in this scenario.
D. Continuous swallowing can be an early sign of bleeding after tonsillectomy, as patients may swallow frequently to clear blood from the throat. If a patient is swallowing more often than normal, it could indicate that they are swallowing blood, which would require immediate intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.