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: Hypoventilation is not a cause of respiratory alkalosis. Hypoventilation leads to respiratory acidosis due to the retention of carbon dioxide (CO2). Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a higher pH (alkaline).

Choice B reason: Panic attacks can cause respiratory alkalosis due to hyperventilation. During a panic attack, a person may breathe rapidly and deeply, leading to excessive loss of CO2. This reduces the CO2 levels in the blood and increases the pH, resulting in respiratory alkalosis.

Choice C reason: Pneumonia is more likely to cause respiratory acidosis or metabolic acidosis rather than respiratory alkalosis. Pneumonia can impair gas exchange, leading to CO2 retention and decreased oxygen levels, which are not typical triggers for respiratory alkalosis.

Choice D reason: Congestive heart failure can lead to respiratory alkalosis, but it is more commonly associated with metabolic acidosis due to poor perfusion and anaerobic metabolism. Hyperventilation in heart failure patients can lead to respiratory alkalosis, but panic attacks are a more direct and common cause.

A. Kussmaul breathing B. Positive Chvostek sign C. Hematemesis D. Distended jugular vein

Correct Answer is B

Explanation

Choice A reason: Kussmaul breathing is a sign of metabolic acidosis, not metabolic alkalosis. It is characterized by deep, labored breathing as the body tries to expel excess carbon dioxide.

Choice B reason: Positive Chvostek sign is an indication of hypocalcemia, which can be associated with metabolic alkalosis. It is a facial muscle twitch that occurs when the facial nerve is tapped.

Choice C reason: Hematemesis, or vomiting blood, is not a clinical manifestation of metabolic alkalosis. It is more related to gastrointestinal bleeding.

Choice D reason: Distended jugular veins are more commonly associated with conditions such as heart failure and fluid overload, not specifically with metabolic alkalosis.

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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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