Exhibits
The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Cerebral edema

Septic shock

Cardiac arrhythmias

Renal failure

Hypotension

Respiratory alkalosis

Answer and Explanation

Correct Answer : A,C,D,E

A. This is a serious complication in DKA, particularly in children, where the shift in osmolality during treatment can lead to fluid shifts into the brain. It can present with neurological deterioration, headache, altered mental status, and even coma.
B.   Septic shock
While infection can precipitate DKA, septic shock itself is not a direct complication of DKA. However, DKA can predispose patients to infections due to impaired immune function, dehydration, and hyperglycemia.
C.   Cardiac arrhythmias
Electrolyte imbalances, particularly hypokalemia or hyperkalemia (depending on treatment phase), can predispose individuals with DKA to cardiac arrhythmias such as ventricular arrhythmias (e.g., ventricular tachycardia) or atrial fibrillation.
D.   Renal failure
Acute kidney injury (AKI) can occur due to dehydration, electrolyte imbalances, and the direct effects of acidosis. However, with prompt and appropriate treatment, renal function typically recovers.
E.   Hypotension
Dehydration and volume depletion are common in DKA due to osmotic diuresis and fluid loss. This can lead to hypovolemic shock and hypotension if not adequately managed with fluid resuscitation.
F Respiratory alkalosis
DKA is associated with metabolic acidosis, not respiratory alkalosis. The body compensates for acidosis by increasing respiratory rate (Kussmaul respirations) to blow off CO2 and normalize pH, but this does not lead to respiratory alkalosis.

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Correct Answer is B

Explanation

B. Respiratory infections can spread via droplets, necessitating airborne precautions and isolation in a private negative pressure room to prevent transmission to other clients and healthcare workers.

A A compound fracture involves an open wound where the bone has punctured the skin. While this client may require isolation precautions due to the open wound, the primary concern is not infectious in nature.

C. Aspiration pneumonia can be caused by inhalation of oral or gastric contents into the lungs, leading to infection. Therefore, such a client does not require isolation.

D Acute ketoacidosis in diabetes mellitus is a metabolic emergency but is not typically contagious or requiring isolation precautions for infection control.

A. Projectile vomiting B. Papilledema C. Restlessness D. Decorticate posturing

Correct Answer is C

Explanation

C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.

A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.

B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.

D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP

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ExhibitsThe nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Exhibits
The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.