The nurse is caring for a 22-year-old female patient who is brought to the emergency department with a new onset of blurred vision and headache. Use the chart to answer the questions.
The nurse recognizes the patient is demonstrating signs of diabetic ketoacidosis (DKA). Which findings support this recognition? Select all that apply.
(Select All that Apply.)
Acetone breath and respiratory pattern
Blurred vision and headache
Nausea and vomiting
History of type 1 DM Appendix removal at age 7
Weekend alcohol ingestion
Tachycardia and hypotension
Insulin pump turned off
Correct Answer : A,C,F,G
A. Acetone breath, characterized by a fruity or acetone-like odor on the patient's breath, is a classic sign of DKA. In addition, Kussmaul respirations, which are deep and labored breathing patterns, can occur as the body attempts to compensate for metabolic acidosis in DKA.
C. Nausea and vomiting are common symptoms of DKA and can occur due to metabolic acidosis, electrolyte imbalances, and gastrointestinal disturbances associated with the condition.
F. Tachycardia and hypotension are signs of hemodynamic instability, which can occur in severe cases of DKA due to dehydration, electrolyte imbalances, and the systemic effects of metabolic acidosis.
G. Turning off an insulin pump can lead to insulin deficiency, which is a precipitating factor for DKA, particularly in patients with type 1 diabetes who rely on continuous insulin therapy. This finding is consistent with the development of DKA.
B. Blurred vision and headache can be symptoms of DKA, although they are not specific to this condition. Elevated blood glucose levels and dehydration associated with DKA can lead to osmotic diuresis and subsequent fluid shifts, which may manifest as headache and visual disturbances.
D. A history of type 1 diabetes mellitus (DM) predisposes the patient to DKA but the history of appendix removal at age 7 is not directly relevant to the current presentation of DKA.
E. Alcohol ingestion can contribute to the development of DKA by inhibiting gluconeogenesis and promoting ketoacidosis, particularly if the patient is not consuming adequate carbohydrates and insulin. However, it is not a direct sign of DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Good control of blood glucose levels and blood pressure is essential in reducing the risk of diabetic retinopathy and its progression. Research has shown that maintaining tight glycemic control and managing hypertension can significantly decrease the likelihood and severity of retinopathy in patients with diabetes.
A. Laser surgery is a treatment option for certain complications of diabetic retinopathy, such as retinal hemorrhage or retinal detachment. However, it's essential to emphasize that prevention through good glycemic control and regular eye exams is key to reducing the risk of these complications, rather than relying solely on surgical interventions after they occur.
B. Cataracts are more common in individuals with diabetes and can be surgically corrected but this statement does not directly address the concern about retinopathy. Cataracts and retinopathy are separate ocular complications of diabetes, each requiring different management strategies.
D. Diabetes remains one of the leading causes of blindness in the United States, primarily due to its association with diabetic retinopathy. While advancements in diabetes management and eye care have helped reduce the incidence of blindness, it is still a significant concern for individuals with diabetes.
Correct Answer is A
Explanation
A. Chocolate contains caffeine and cocoa, both of which can relax the lower esophageal sphincter (LES) and increase the risk of acid reflux. Additionally, chocolate is high in fat, which can further exacerbate symptoms of GERD. Therefore, chocolate is often recommended to be avoided by individuals with GERD.
B. Oatmeal is generally considered a bland and low-acid food that is unlikely to trigger symptoms of GERD. In fact, oatmeal is often recommended as part of a GERD-friendly diet due to its high fiber content, which can help absorb stomach acid and promote digestive health.
C. Apples are generally considered to be low in acid and high in fiber, making them a relatively safe fruit choice for individuals with GERD. However, some individuals may find that certain varieties of apples or apple products (such as apple juice) can exacerbate their GERD symptoms.
D. Nonfat milk is generally considered to be a low-fat and low-acid beverage that is unlikely to trigger symptoms of GERD. However, some individuals may find that consuming dairy products, including milk, can exacerbate their GERD symptoms.
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