A nurse is collecting data from a client who has diabetes mellitus.
Which of the following findings indicates that the client is experiencing DKA?
Confusion
Polydipsia
Rapid pulse
Clammy skin
Correct Answer : A,B,C
Choice A rationale:
Confusion can be a symptom of Diabetic Ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
Choice B rationale:
Polydipsia, or excessive thirst, is another common symptom of DKA. High blood sugar levels can cause increased urination, leading to dehydration and an increased feeling of thirst.
Choice C rationale:
A rapid pulse is also a symptom of DKA. This is because the body is trying to compensate for the low amount of fluid in your blood vessels due to dehydration.
Choice D rationale:
Clammy skin is not typically a symptom of DKA. It’s more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar) which is what occurs in DKA1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is C
Explanation
Choice A rationale:
The client stating, “I haven’t had anything to eat or drink since last night” is not a cause for concern. This is because patients are often advised to fast before undergoing certain medical procedures or tests, including an intravenous pyelogram (IVP).
Fasting helps to ensure that the test results are accurate and not influenced by recent food or drink consumption.
Choice B rationale:
The client expressing that “The last time I voided it was painful” could be related to their recurrent kidney stones. Kidney stones can cause discomfort or pain during urination. However, this statement does not necessarily require additional data collection in the context of an IVP. The pain could be a symptom of the kidney stones rather than a contraindication for the IVP1.
Choice C rationale:
The statement “I took my metformin before breakfast” is of concern. Metformin is a medication used to treat type 2 diabetes. It is important for the nurse to collect additional data about this statement because metformin can potentially interact with the iodine-based contrast dye used in an IVP. This interaction can increase the risk of lactic acidosis, a serious and potentially lifethreatening condition. Therefore, patients are often advised to stop taking metformin before and for a couple of days after having an IVP12. Choice D rationale:
The client mentioning, “I took a laxative yesterday” is not necessarily alarming. Laxatives are often used before an IVP to clear the bowels, which helps to ensure clear images during the procedure. Therefore, this statement does not require additional data collection in the context of an IVP1.
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