Patient Data.
What are the signs and symptoms of DKA? Select all that apply.
Hyperglycemia.
Ketonuria.
Metabolic acidosis.
Hypokalemia.
Dehydration.
Kussmaul respirations
Correct Answer : A,B,C,E,F
Choice A rationale:
Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise1. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.
Choice B rationale:
Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.
Choice C rationale:
Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis1.
Choice D rationale:
Hypokalemia is not a symptom of DKA. In fact, patients with DKA often have high potassium levels in their blood at presentation because acidosis causes potassium to move from inside the cells into the bloodstream1. However, during treatment for DKA, when insulin is administered and acidosis is corrected, potassium moves back into the cells and can lead to low potassium levels or hypokalemia1.
Choice E rationale:
Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.
Choice F rationale:
Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Choice B rationale:
Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face.Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications
Choice C rationale:
An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.
Choice D rationale:
Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.
Correct Answer is C
Explanation
Choice A rationale:
Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.
Choice B rationale:
Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.
Choice C rationale:
Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.
Choice D rationale:
Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.