The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

Hypotension

Bradycardia

Polyphagia

Rapid, deep respiration

Answer and Explanation

The Correct Answer is A

Choice A reason: Hypotension, or low blood pressure, is a common indicator of fluid volume deficit. When a patient is dehydrated or has a significant loss of fluids, their blood volume decreases, leading to lower blood pressure. This condition requires immediate attention and management to prevent complications such as shock or organ failure. Monitoring and correcting fluid balance is crucial in managing patients with diabetic ketoacidosis, making hypotension a significant assessment finding.

Choice B reason: Bradycardia, or slow heart rate, is not typically associated with fluid volume deficit. It is more often related to other conditions such as heart block, hypothyroidism, or use of certain medications. In the context of diabetic ketoacidosis, fluid volume deficit would not manifest primarily as bradycardia.

Choice C reason: Polyphagia, or excessive hunger, is a symptom commonly associated with diabetes mellitus but does not indicate fluid volume deficit. Polyphagia results from the body's inability to use glucose properly, leading to increased hunger. It is not directly related to the patient's hydration status or fluid volume.

Choice D reason: Rapid, deep respiration, also known as Kussmaul breathing, is a compensatory mechanism in response to metabolic acidosis, a hallmark of diabetic ketoacidosis. While it is an important clinical sign, it does not specifically indicate fluid volume deficit. Kussmaul respiration occurs due to the body's attempt to expel excess carbon dioxide and correct the acid-base imbalance.

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Correct Answer is B

Explanation

Choice A reason: Performing weekly occult blood testing with gastric analysis is not typically required for managing IBD at home. While monitoring for blood in the stool can be important, weekly testing and gastric analysis are more invasive and usually performed under specific medical instructions rather than as a routine home care intervention.

Choice B reason: Discussing nutritional management with the inclusion of a high-protein, high-vitamin diet is crucial for patients with IBD. These patients often experience malnutrition due to poor absorption and increased nutritional needs during flare-ups. A high-protein, high-vitamin diet can help promote healing, maintain muscle mass, and prevent deficiencies. This intervention supports overall health and recovery.

Choice C reason: Leaving the ostomy site open to air for an hour each day when changing the appliance is not recommended. Ostomy sites need to be kept clean and protected to prevent infection and skin irritation. Instead, the focus should be on proper cleaning and secure application of the ostomy appliance.

Choice D reason: Instructing the patient and family on how to give medications through their G-tube is not relevant if the patient has an ostomy. A G-tube is used for feeding and medication administration in patients with impaired oral intake, which is not indicated in this scenario. The focus should be on ostomy care and management.

A. Joint swelling, tenderness, and pain with movement. B. Red ulcers on the buccal mucosa. C. Malar and discoid rashes. D. Dark, foamy urine.

Correct Answer is D

Explanation

Choice A reason: Joint swelling, tenderness, and pain with movement are common symptoms of systemic lupus erythematosus (SLE) but are not immediately life-threatening. They should be managed but are not the priority in this case.

Choice B reason: Red ulcers on the buccal mucosa are a concerning finding in SLE and can indicate active disease, but they are not the priority compared to signs of potential kidney involvement.

Choice C reason: Malar and discoid rashes are typical

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The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

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