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 D
Explanation
A. In this type of traction, the child’s buttocks should be elevated slightly off the bed to maintain the correct alignment and reduce pressure on the skin. However, a 15° angle may not be specifically necessary for indicating proper traction; what matters more is that the child is positioned correctly and comfortably.
B. While a reduction in pain can indicate that the traction is effective and that the fracture is stabilized, pain management is also influenced by medication and other factors. Therefore, while this is a positive finding, it is not the most definitive indicator of proper traction.
C. However, while it is essential that the pins are secure, the effectiveness of traction is more directly related to the positioning and suspension of the legs rather than just the pin security alone.
D. In Bryant's traction, the legs should be suspended to ensure proper alignment and immobilization of the fractured femur. The traction's effectiveness is best assessed by observing that the legs are correctly suspended and aligned, allowing for the necessary rest and healing of the bone.
Correct Answer is ["A","D"]
Explanation
A. Patients are often advised to avoid straining during bowel movements and bending at the waist to reduce intraocular pressure and the risk of complications after cataract surgery. This is crucial for promoting healing and preventing dislodgement of the lens.
B. While good lighting can be important for safety and visibility, patients are often advised to avoid excessively bright lights or glare, especially after surgery, as it can be uncomfortable and may not be beneficial during the recovery period. Patients may need to use softer lighting to avoid discomfort.
C. After cataract surgery, patients are typically advised to lie on their back or the non-operative side to avoid pressure on the eye that underwent surgery. Lying on the abdomen is not recommended and could pose a risk to the surgical site.
D. Patients are often instructed to avoid heavy lifting for a period after surgery to prevent increased intraocular pressure and potential complications. Lifting more than 15 lbs is generally discouraged during the initial recovery phase.
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