The nurse is caring for a child admitted to the emergency center in diabetic ketoacidosis. Which clinical manifestations would the nurse most likely note in this child?
Hyperactive and restless behavior
Slow pulse
Pale and moist skin
Deep rapid respirations and acetone odor to breath
The Correct Answer is D
A. Children with DKA are more likely to exhibit fatigue, lethargy, or altered mental status rather than hyperactivity. Hyperactivity may be seen in early stages of mild hypoglycemia, but DKA involves significant metabolic derangements that usually depress CNS activity. Therefore, hyperactivity is not a characteristic manifestation of DKA.
B. DKA usually causes tachycardia due to dehydration and compensatory mechanisms to maintain perfusion. Hypovolemia reduces circulating blood volume, prompting the heart to beat faster to maintain cardiac output. Bradycardia is uncommon and may indicate severe electrolyte imbalance or late-stage shock rather than typical DKA presentation.
C. In DKA, dehydration is a major concern. Children typically present with warm, dry, flushed skin due to fluid loss, hyperosmolarity, and osmotic diuresis. Pale, clammy, or moist skin is more characteristic of hypoglycemia or acute shock from other causes, not DKA.
D. This is the most characteristic finding in DKA. Kussmaul respirations, which are deep and rapid breaths, develop as a compensatory mechanism for metabolic acidosis. The body attempts to "blow off" carbon dioxide to partially correct the acid-base imbalance. The acetone (fruity) odor results from the accumulation of ketone bodies (acetoacetate, β-hydroxybutyrate, and acetone) in the blood. These ketones arise from fat breakdown secondary to insulin deficiency. This manifestation is both specific and clinically significant, helping differentiate DKA from other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Osteomyelitis is a bone infection, not a malignancy. Referral to oncology is unnecessary unless there is an unrelated suspected malignancy. This does not align with standard osteomyelitis discharge planning.
B. Proper nutrition for a child with osteomyelitis should be well-balanced with adequate protein to support tissue repair and immune function. A high-fat, low-protein diet would be counterproductive and is not recommended.
C. Children recovering from osteomyelitis should avoid strenuous activity until cleared by the healthcare provider. Premature return to physical activity can risk re-injury, delayed healing, or exacerbation of infection.
D. Osteomyelitis often requires prolonged intravenous antibiotic therapy, sometimes lasting several weeks. A home healthcare referral allows for safe administration of IV antibiotics, monitoring for complications, and ongoing patient/family education, which is an essential component of discharge planning.
Correct Answer is C
Explanation
A. Allergic conjunctivitis and allergic rhinitis are not caused by bacteria, so antibiotics offer no benefit. Using antibiotics unnecessarily increases the risk of resistance and exposes the child to unnecessary medication side effects. This statement shows the parent has misunderstood the teaching.
B. The child’s symptoms, itchy, watery eyes, sneezing, and clear rhinorrhea, are classic findings of allergic conjunctivitis and allergic rhinitis, not a viral infection. Viral infections usually involve redness, discomfort, and often systemic symptoms such as fever, malaise, or thicker nasal secretions.
C. Allergic symptoms are caused by an immune response to allergens, not bacteria or viruses. Therefore, antibiotics are not required. Treatment focuses on antihistamines, allergen avoidance, and symptomatic relief, making this the statement that best reflects proper understanding.
D. Allergic conjunctivitis is not contagious, so notifying the daycare is not required. This response suggests the parent believes the condition may spread to others, which indicates misunderstanding of the teaching.
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