A nurse is caring for a patient diagnosed with diabetic ketoacidosis.
Which of the following symptoms should the nurse expect?
Cheyne-Stokes breathing.
Acetone odor to breath.
Blood glucose level below 40 mg/dL.
Malignant hypertension.
The Correct Answer is B
Choice A rationale
Cheyne-Stokes breathing, characterized by a cycle of increasing and decreasing respiratory rate and depth, is not a typical symptom of diabetic ketoacidosis (DKA). DKA is more commonly associated with Kussmaul breathing, which is rapid, deep, and labored.
Choice B rationale
An acetone odor to the breath is a classic symptom of DKA. This is due to the body breaking down fat for energy, which produces ketones. These ketones can cause the breath to smell fruity or like nail polish remover.
Choice C rationale
A blood glucose level below 40 mg/dL is not a symptom of DKA. In fact, DKA is characterized by high blood glucose levels, typically above 250 mg/dL111213.
Choice D rationale
Malignant hypertension is not a typical symptom of DKA. While DKA can cause dehydration and electrolyte imbalances that may affect blood pressure, it does not typically cause malignant hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pyorrhea, also known as periodontitis, is a severe gum infection that damages gums and can destroy the jawbone. It is not related to bleeding between menstrual periods.
Choice B rationale
Dysmenorrhea refers to painful periods, not bleeding between periods.
Choice C rationale
Menorrhagia is a term used to describe heavy or prolonged menstrual bleeding, not bleeding between periods.
Choice D rationale
Metrorrhagia is the term used to describe bleeding between menstrual periods. When documenting this finding, it’s helpful to keep a record of the menstrual cycle, noting when periods begin and end, the heaviness and duration of the flow, and when and how much bleeding occurs between periods.
Correct Answer is A
Explanation
Choice A rationale
Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.
Choice B rationale
Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.
Choice C rationale
Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
Choice D rationale
Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
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