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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While altered mental status can occur in older adults with pneumonia, especially due to hypoxia or infection, it is often a result of more advanced disease or complications rather than an early symptom. Dehydration can also occur but is not a direct symptom of pneumonia.
B. Hemoptysis (coughing up blood) is not a common early symptom of pneumonia, especially in older adults. Dyspnea (difficulty breathing) may occur, but it generally arises as the pneumonia worsens. These symptoms might not be the first to present.
C. Pleuritic chest pain (pain upon breathing) can be associated with pneumonia but is not necessarily an early symptom, especially in the elderly. Hypertension may be present but is not a hallmark of pneumonia and can vary widely among patients.
D. Fever and chills are common initial symptoms of pneumonia and are part of the body’s response to infection. In elderly patients, fever may sometimes be less pronounced or atypical, but it is still one of the first signs of pneumonia.
Correct Answer is B
Explanation
A. Ondansetron is not indicated for treating diarrhea. While nausea can accompany diarrhea, ondansetron specifically targets nausea and vomiting rather than the underlying causes of diarrhea.
B. Ondansetron is primarily used to prevent and treat nausea and vomiting, particularly those associated with chemotherapy, radiation therapy, and postoperative recovery. If a patient is experiencing nausea and vomiting, ondansetron would be the appropriate medication to administer.
C. Ondansetron is not indicated for managing pain. Incisional pain is typically treated with analgesics, not antiemetics. While postoperative patients may experience nausea, ondansetron would not be used solely for pain relief.
D. Paralytic ileus is a condition characterized by the lack of movement in the intestines, leading to a blockage. While nausea and vomiting can occur in this condition, ondansetron is not a treatment for the underlying issue of ileus. The focus would be on managing the ileus and any complications that arise.
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