An adolescent client with Type 1 diabetes mellitus is admitted to the emergency room for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?
No appetite and hypertension
Cold, clammy skin and irritability
Sweating and tremors.
Fruity breath odor and confusion
The Correct Answer is D
A. While anorexia, nausea, and vomiting are common in diabetic ketoacidosis (DKA) due to metabolic acidosis and electrolyte imbalances, hypertension is not typical. In fact, hypotension is more common in DKA because of severe dehydration caused by osmotic diuresis (excessive urination to remove glucose). Thus, hypertension would not be an expected finding.
B. Cold, clammy skin and irritability are classic signs of hypoglycemia, not DKA. Hypoglycemia triggers the sympathetic nervous system, causing diaphoresis, pallor, and agitation, which are distinct from the hyperglycemic and dehydrated state seen in DKA.
C. Sweating and tremors are also indicative of hypoglycemia. In DKA, the body is in a hyperglycemic, dehydrated state, often presenting with warm, dry skin due to fluid loss, not the cool, clammy skin seen in low blood glucose episodes.
D. Fruity or acetone-smelling breath results from ketone accumulation due to fat metabolism in the absence of sufficient insulin. Confusion and altered mental status are consequences of dehydration, hyperglycemia, and electrolyte imbalances, particularly sodium and potassium disturbances. Other hallmark DKA signs include polyuria, polydipsia, abdominal pain, vomiting, tachypnea (Kussmaul respirations), and lethargy. Prompt recognition of these manifestations is critical to initiate fluid replacement, insulin therapy, and electrolyte correction to prevent life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Antifungal ointments, such as clotrimazole or miconazole, are used to treat fungal infections like tinea capitis or ringworm. Pediculosis capitis is caused by head lice (an ectoparasite), not a fungus, so antifungal ointments are ineffective. Using them can delay appropriate treatment and does not eradicate lice or nits.
B. Hydrogen peroxide is sometimes used for minor wound cleaning or hair bleaching, but it has no proven effect on lice or nits. Its application to the scalp can cause skin irritation, dryness, and discomfort without treating the underlying infestation, making it an inappropriate intervention.
C. Head lice are species-specific parasites that infest humans and cannot survive on pets. Treating animals is unnecessary and does not prevent reinfestation. Resources and efforts should instead focus on treating the affected child, close human contacts, and contaminated personal items.
D. Lice and nits can survive on bedding, clothing, hats, and towels. Washing these items in hot water and drying them on high heat for at least 20 minutes effectively kills lice and prevents reinfestation. Items that cannot be washed can be sealed in an airtight plastic bag for 14 days. This environmental control is an essential component of comprehensive pediculosis management.
Correct Answer is A
Explanation
A. This statement indicates a need for further teaching. Isotretinoin is highly teratogenic and can cause severe birth defects. It is never safe during pregnancy, and strict pregnancy prevention measures must be followed.
B. This statement is accurate. To prevent pregnancy, clients must use two reliable forms of contraception starting one month prior to therapy, throughout treatment, and for one month after discontinuation, as recommended by the iPLEDGE program.
C. This statement is accurate. Isotretinoin can cause hyperlipidemia, so monitoring lipid levels periodically during therapy is essential to detect and manage potential complications.
D. This statement is accurate. Avoiding pregnancy is mandatory due to the high teratogenic risk associated with Isotretinoin. Clients must follow strict pregnancy prevention protocols.
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