A nurse is caring for a client in the emergency department.

Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Skin turgor

Blood glucose greater than expected reference range

Creatinine greater than expected reference range

Urine ketones

Blood pH greater than expected reference range

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS. A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS. An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.

The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin. A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.

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Correct Answer is D

Explanation

A. Metabolic alkalosis is characterized by elevated pH and HCO3.

B. Respiratory alkalosis is characterized by elevated pH and decreased PaCO2.

C. Metabolic acidosis is characterized by decreased pH and HCO3.

D. Respiratory acidosis is indicated by a decreased pH and elevated PaCO2, which aligns with the client's ABG results.

A. Cheyne-Stokes respirations B. Pupillary dilation C. Decorticate posturing D. Altered level of consciousness

Correct Answer is D

Explanation

A. Cheyne-Stokes respirations are a later sign of deteriorating neurological status, indicating severe brain dysfunction.

B. Pupillary dilation is a significant but later sign of deteriorating neurological status, often indicating pressure on the brainstem.

C. Decorticate posturing is a serious sign of deteriorating neurological status, but it occurs after alterations in consciousness.

D. An altered level of consciousness is typically the first sign of deteriorating neurological status, reflecting changes in brain function before other severe symptoms appear.

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A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's ABG results and notes pH 7.3 (7.35 to 7.45), PaO2 81 mm Hg (80 to 100 mm Hg), PaCO2 50 mm Hg (35 to 45 mm Hg), and HCO, 26 mEq/L (21 to 28 mEq/L). Which of the following acid-base imbalances is the client experiencing?

Correct Answer is D

Explanation

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is D

Explanation

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A nurse is caring for a client in the emergency department.

Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.