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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason
While coronary artery spasm can cause chest pain, it is not the typical cause of unstable angina. Unstable angina is generally due to atherosclerotic heart disease, where plaque buildup in the coronary arteries restricts blood flow. This statement does not fully reflect an understanding of the condition.
Choice B Reason
Beta blockers are often prescribed to manage angina as they reduce the heart's workload and oxygen demand. However, they do not always prevent angina pain, especially in the case of unstable angina, which can occur unpredictably and not just during exertion. This statement shows partial understanding but lacks the urgency associated with unstable angina.
Choice C Reason
Seeking immediate medical attention when experiencing angina pain is crucial, especially in the case of unstable angina, which can signal an impending heart attack. This statement indicates that the client understands the seriousness of their condition and the need for prompt action.
Choice D Reason
While rest can help alleviate stable angina pain, unstable angina is less predictable and may not be relieved by rest. This type of angina requires medical evaluation to prevent more serious complications, such as myocardial infarction. This statement does not convey an adequate understanding of the condition.
Correct Answer is B
Explanation
Choice a reason:
Diuretic use is not typically associated with an increased risk of developing fibromyalgia. Diuretics are commonly used to treat conditions like hypertension and edema by helping the body eliminate excess fluid, but they do not contribute to the onset of fibromyalgia¹.
Choice b reason:
Emotional or physical trauma has been identified as a risk factor for fibromyalgia. Individuals who experience significant stress or traumatic events may develop the disorder due to changes in how their central nervous system processes pain. Stress can lead to long-lasting effects on the body and may trigger fibromyalgia or worsen its symptoms²³⁴.
Choice c reason:
Being overweight is not a direct risk factor for fibromyalgia, but it can exacerbate symptoms in those who have the condition. Excess weight can increase the strain on the body and may contribute to the chronic pain and fatigue associated with fibromyalgia. However, it is not considered a causative factor¹.
Choice d reason:
Being an adolescent male is not a recognized risk factor for fibromyalgia. The disorder is more commonly diagnosed in women, and while it can occur at any age, it is most often diagnosed during middle age. Gender and age alone are not sufficient to determine the risk of developing fibromyalgia.
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