A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
Blood glucose level below 40 mg/dL
Malignant hypertension
Cheyne-Stokes breathing
Acetone odor to breath
The Correct Answer is D
A. Blood glucose level below 40 mg/dL: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with blood glucose levels significantly elevated above normal, often exceeding 250 mg/dL. A glucose level below 40 mg/dL would indicate hypoglycemia, which is not a feature of DKA.
B. Malignant hypertension: Malignant hypertension is a condition characterized by extremely high blood pressure and is not directly associated with DKA. DKA primarily involves issues with glucose and acid-base balance rather than hypertension.
C. Cheyne-Stokes breathing: Cheyne-Stokes breathing is a specific pattern of periodic breathing typically seen in severe neurologic conditions or heart failure, not in DKA. DKA is associated with Kussmaul breathing, which is deep and rapid breathing as the body attempts to compensate for metabolic acidosis.
D. Acetone odor to breath: An acetone (fruity) odor to the breath is a classic sign of DKA due to the presence of ketones in the blood and urine. This occurs because the body is breaking down fatty acids for energy, leading to the production of ketones, which are then excreted through the breath and urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood glucose level below 40 mg/dL: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with blood glucose levels significantly elevated above normal, often exceeding 250 mg/dL. A glucose level below 40 mg/dL would indicate hypoglycemia, which is not a feature of DKA.
B. Malignant hypertension: Malignant hypertension is a condition characterized by extremely high blood pressure and is not directly associated with DKA. DKA primarily involves issues with glucose and acid-base balance rather than hypertension.
C. Cheyne-Stokes breathing: Cheyne-Stokes breathing is a specific pattern of periodic breathing typically seen in severe neurologic conditions or heart failure, not in DKA. DKA is associated with Kussmaul breathing, which is deep and rapid breathing as the body attempts to compensate for metabolic acidosis.
D. Acetone odor to breath: An acetone (fruity) odor to the breath is a classic sign of DKA due to the presence of ketones in the blood and urine. This occurs because the body is breaking down fatty acids for energy, leading to the production of ketones, which are then excreted through the breath and urine.
Correct Answer is D
Explanation
A. Empyema: Empyema refers to the accumulation of pus in the pleural cavity, not a type of pneumonia. It is usually a complication of pneumonia rather than a description of the pneumonia itself.
B. Bronchopneumonia: Bronchopneumonia involves patchy consolidation that is usually scattered throughout the lung fields, not confined to a single lobe. It affects the bronchi and surrounding lung parenchyma.
C. Severe pneumonia: The term "severe pneumonia" describes the severity of the disease but does not specify the pattern of consolidation. It does not indicate whether the consolidation is lobar or patchy.
D. Lobar pneumonia: Lobar pneumonia is characterized by consolidation that involves an entire lobe of the lung. It typically presents with homogenous radiographic opacification of one or more lobes, often caused by pathogens such as Streptococcus pneumoniae.
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