When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?
Drink electrolyte fluid replacements.
Give a dose of regular insulin as prescribed.
Resume normal physical activity.
Measure urine output over the next 24 hours.
The Correct Answer is B
Choice A rationale:
Drinking electrolyte fluid replacements may be necessary if the client is dehydrated due to diabetic ketoacidosis (DKA). However, addressing the increased thirst, which is a sign of DKA, should involve insulin administration to correct the underlying problem of high blood sugar.
Choice B rationale:
Giving a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a client with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.
Choice C rationale:
Resuming normal physical activity may not be advisable when a client is experiencing early signs of DKA. Strenuous physical activity can exacerbate hyperglycemia, and the primary focus should be on insulin administration and rehydration.
Choice D rationale:
Measuring urine output over the next 24 hours is important for monitoring hydration status in a client with DKA. However, the immediate priority is to address the increased thirst and hyperglycemia with insulin therapy.
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Correct Answer is C
Explanation
Choice A rationale:
Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.
Choice B rationale:
Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.
Choice C rationale:
Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.
Choice D rationale:
Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.
Correct Answer is D
Explanation
Choice A rationale:
Systemic autoimmune vasculopathy is not a typical underlying disease pathology associated with a waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice B rationale:
Autonomic neuropathy may manifest with a variety of symptoms, including autonomic dysregulation, but it is not a common underlying pathology leading to a waddling gait and frequent falls in a child. This choice is not relevant to the symptoms described.
Choice C rationale:
Impaired neuron function can result in various neurological symptoms, but it does not specifically explain the waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice D rationale:
Muscle fiber degeneration is the most appropriate explanation for the symptoms of a waddling gait and frequent falls in a 5-year-old child. These symptoms are indicative of a neuromuscular disorder known as Duchenne muscular dystrophy (DMD), which involves progressive muscle weakness and degeneration. DMD is characterized by the loss of muscle fibers and is a common cause of a waddling gait and falls in affected children. Therefore, choice D is the correct answer based on the understanding of the underlying disease pathology.
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