A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
Periods of apnea for 20 seconds
Paradoxic respirations of 26/min
Shallow respirations of 10/min
Deep respirations of 32/min
The Correct Answer is D
A. Periods of apnea are not typical for DKA and may indicate other respiratory issues.
B. Paradoxic respirations are abnormal and occur when chest and abdomen move in opposite directions, which is not typically associated with DKA.
C. Shallow respirations are not typical of DKA; they would indicate respiratory depression or other issues.
D. Deep, rapid respirations (Kussmaul respirations) are characteristic of diabetic ketoacidosis (DKA). They occur as the body tries to compensate for acidosis by exhaling more carbon dioxide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.
B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.
C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.
D. A heart rate of 72/min is normal and does not indicate immediate concern.
Correct Answer is A
Explanation
A. The toddler’s behavior—sitting quietly and turning away from the nurse—suggests anxiety due to separation from the mother. This is typical of toddlers who experience distress when separated from caregivers.
B. Developing autonomy is a developmental task of toddlers, but the behavior described (turning away from the nurse and seeking comfort through thumb-sucking) indicates distress rather than an expression of independence.
C. Regression can occur in toddlers when they experience stress, but the behavior here seems more related to anxiety than a return to earlier developmental behaviors.
D. Resentment toward the mother is unlikely in this situation; the behavior is more indicative of separation anxiety.
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