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A nurse is caring for a client with diabetic ketoacidosis (DKA). The client asks why he has this condition. What is the nurse's best answer?

"DKA happens when the body's cells can't respond appropriately to the insulin being produced and blood glucose levels rise."

"DKA is a metabolic disorder generally resulting from getting sick while having diabetes mellitus type 2."

"DKA can only be acquired in a client with diabetes mellitus type 1 who experiences septic shock."

"DKA results from the complete absence of insulin resulting from poorly controlled or undiagnosed diabetes mellitus type 1."

Answer and Explanation

The Correct Answer is D

A. DKA occurs due to a significant deficiency of insulin rather than issues with cell response to insulin. The condition leads to high blood glucose and ketone production because there is not enough insulin to regulate glucose levels effectively.
B. DKA is primarily associated with diabetes mellitus type 1, not type 2. It can occur due to a lack of insulin and is not solely caused by illness, although illness can exacerbate it.
C. DKA is not limited to clients with diabetes mellitus type 1 who experience septic shock. It can occur in anyone with type 1 diabetes due to severe insulin deficiency, though septic shock can complicate the condition.
D. DKA results from a complete absence of insulin, which is characteristic of poorly controlled or undiagnosed diabetes mellitus type 1. This insulin deficiency leads to elevated blood glucose levels and ketone formation.

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Correct Answer is C

Explanation

A. Desmopressin acetate is used to treat diabetes insipidus, not SIADH. In SIADH, there is excessive antidiuretic hormone causing fluid retention and dilutional hyponatremia, so this medication would not be appropriate.
B. Maintaining an IV infusion of 0.45% sodium chloride is not appropriate for SIADH, as this solution can further dilute sodium levels. Treatment usually involves hypertonic saline or fluid restriction.
C. Restricting fluid intake is a key management strategy for SIADH to address the fluid overload and help correct the low sodium levels. This action directly targets the root cause of the hyponatremia by reducing fluid intake.
D. Providing a diet with 2 g of sodium per day may not be sufficient or appropriate for treating SIADH-related hyponatremia. Fluid restriction is more critical in managing this condition.

A. Use a portable electronic thermometer to take the client's temperature. B. Wipe the stethoscope with alcohol after use. C. Remove the protective gown before leaving the client's room. D. Remove the protective gown before removing gloves.

Correct Answer is C

Explanation

A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.

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A nurse is caring for a client with diabetic ketoacidosis (DKA). The client asks why he has this condition. What is the nurse's best answer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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