The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

Glucose level at least 600 mg/dL

Fruity, acetone smell to the breath

Absence of ketones in the urine

Polyuria and polydipsia

Rapid, deep breathing.

Answer and Explanation

Correct Answer : B,D,E

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

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Correct Answer is B

Explanation

Choice A Reason
Bradycardia, which is a slower than normal heart rate, is not typically a sign of hypoglycemia. Hypoglycemia can actually cause an increase in heart rate due to the release of adrenaline in response to low blood sugar levels.

Choice B Reason
Tremors are a common sign of hypoglycemia and are caused by the release of adrenaline. When blood sugar levels fall too low, the body releases adrenaline as a part of the "fight or flight" response, which can lead to shaking or trembling.

Choice C Reason
Kussmaul's respirations, which are deep and labored breathing patterns, are more commonly associated with diabetic ketoacidosis, not hypoglycemia. This type of breathing is the body's response to acidosis and is not indicative of low blood sugar levels.

Choice D Reason
Polyuria, or excessive urination, is not a sign of hypoglycemia. It is more commonly associated with hyperglycemia, as the body attempts to eliminate excess glucose through urine.

A. Give the ordered dose of dantrolene. B. Call the physician for an order for metoprolol. C. Increase the rate of lactated Ringer's. D. Ask the physician to order liver function tests.

Correct Answer is A

Explanation

Choice A Reason:
Dantrolene is used in the management of malignant hyperthermia, a life-threatening complication characterized by muscle rigidity and elevated temperature, often triggered by certain anesthetics. The patient's symptoms of muscle rigidity and brown urine, which may indicate myoglobinuria, along with elevated temperature and heart rate, are suggestive of this condition. Dantrolene acts by reducing calcium release from the sarcoplasmic reticulum of skeletal muscle, thereby reducing muscle contraction and metabolic demand.

Choice B Reason:
Metoprolol, a beta-blocker, is not the first-line treatment for symptoms suggestive of malignant hyperthermia. While it can reduce heart rate and blood pressure, it does not address the underlying pathophysiology of malignant hyperthermia and is not indicated in this scenario.

Choice C Reason:
Increasing the rate of lactated Ringer's solution is not the primary intervention for malignant hyperthermia. While maintaining hydration is important, it does not directly counteract the pathophysiological processes at play in malignant hyperthermia.

Choice D Reason:
While liver function tests can be important in assessing overall organ function post-operatively, they are not the immediate priority in a suspected case of malignant hyperthermia. The priority is to treat the acute and life-threatening symptoms first.

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The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

A common sign of hypoglycemia in a client diagnosed with diabetes is:

Correct Answer is B

Explanation

The nurse is assessing a post-operative client and notices that the client's urine is brown and they are experiencing muscle rigidity. The vital signs are T: 102.5 F; HR: 112; RR: 20 and BP 124/84. What is the most appropriate nursing action?

Correct Answer is A

Explanation

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