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. Diaper dermatitis typically affects the diaper area and presents as red, inflamed skin, sometimes with small papules, but it rarely forms moist, weeping blisters over widespread areas or becomes thickened and scaly as seen in chronic eczema.
B. Contact dermatitis occurs after exposure to an irritant or allergen. It usually presents as localized redness, itching, and sometimes vesicles, but it does not typically lead to chronic skin thickening or widespread scaling unless exposure is recurrent and prolonged.
C. Seborrheic dermatitis usually affects areas with high sebaceous gland activity, like the scalp, face, and upper trunk. It presents with greasy, yellowish scales and mild erythema but rarely causes moist, weeping blisters or the thickened, raw skin described in this question.
D. Atopic dermatitis (eczema) is a chronic, relapsing inflammatory skin disorder. It is characterized by red bumps, intense pruritus, and lesions that can form moist, weeping blisters in acute flares. Over time, the skin may become scaly, raw, or lichenified (thickened) due to chronic scratching and inflammation. These features help distinguish atopic dermatitis from other pediatric skin conditions.
Correct Answer is B
Explanation
A. This statement is appropriate for school-age children using standard subcutaneous insulin injection techniques, especially with shorter needles. A 90-degree angle ensures the insulin is delivered into the subcutaneous tissue rather than muscle, which allows for consistent absorption.
B. This statement indicates a need for further teaching. Aspiration (pulling back the plunger to check for blood) is not recommended for subcutaneous insulin injections, as it is unnecessary and can increase pain or tissue trauma. Modern guidelines advise injecting directly into the subcutaneous tissue without aspiration.
C. This statement is appropriate. Rotating injection sites within the same general area prevents lipodystrophy (thickened or atrophied subcutaneous tissue) and ensures consistent insulin absorption.
D. This statement is appropriate. Subcutaneous insulin injections can be administered in areas with adequate subcutaneous fat, such as the abdomen, outer thigh, upper arm, or buttocks, with site rotation to prevent tissue damage and maintain consistent absorption.
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