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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Foot ulcers and delayed wound healing are related to diabetes but are considered macrovascular complications. Microvascular complications specifically refer to damage to small blood vessels.
Choice B reason: Stroke prevention and cardiac health are important but are related to macrovascular complications of diabetes. The focus here is on microvascular complications.
Choice C reason: Retinopathy and nephropathy are microvascular complications of diabetes. These conditions result from damage to small blood vessels in the eyes and kidneys, respectively. Diabetic retinopathy can lead to vision loss, while diabetic nephropathy can lead to kidney failure. It is important to monitor for these complications and manage blood glucose levels to prevent or slow their progression.
Choice D reason: Hypertension management and cholesterol control are important for overall cardiovascular health but are related to macrovascular complications. The discussion should focus on microvascular complications specific to diabetes.
Correct Answer is A
Explanation
Choice A reason: The order to administer Hydrochlorothiazide should be clarified because thiazide diuretics can increase calcium levels, which could worsen hypercalcemia in a patient with a history of hyperparathyroidism.
Choice B reason: Monitoring intake and output and daily weights are essential for managing fluid balance in heart failure patients and do not need clarification.
Choice C reason: Administering Calcitonin helps lower calcium levels, which is appropriate for treating hypercalcemia in a patient with hyperparathyroidism.
Choice D reason: Preparing the patient for possible hemodialysis may be necessary if the patient's kidney function deteriorates, especially with elevated BUN and creatinine levels.
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