A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

Rationale:

A. Tachycardia: Tachycardia is common in diabetic ketoacidosis (DKA) due to dehydration, electrolyte imbalances, and compensatory mechanisms for hypotension. The heart rate increases to maintain adequate perfusion in response to fluid loss and acidosis.

B. HCO3 in expected range: In DKA, bicarbonate (HCO3) levels are decreased due to metabolic acidosis. The body uses bicarbonate to buffer excess ketone acids, so HCO3 is typically below the normal range, not within expected limits.

C. Increased PaCO2: In DKA, PaCO2 is usually decreased due to Kussmaul respirations (deep, rapid breathing) as the body attempts to compensate for metabolic acidosis by blowing off CO2. Elevated PaCO2 would indicate hypoventilation, which is not characteristic of DKA.

D. Hyperreflexia: DKA does not typically cause hyperreflexia. Neurological changes, if present, are more likely to involve lethargy, confusion, or coma due to severe acidosis, dehydration, and electrolyte imbalances, rather than exaggerated reflexes.

Rationale:

A. Forearm: The forearm is generally used for intradermal injections, such as tuberculin or allergy testing, rather than subcutaneous injections. It has limited subcutaneous tissue and is not ideal for medications requiring slower absorption.

B. Vastus lateralis: The vastus lateralis is a preferred site for intramuscular injections, particularly in infants and young children, due to its large muscle mass. It is not the first choice for subcutaneous injections because absorption dynamics differ.

C. Ventrogluteal: The ventrogluteal site is a preferred intramuscular injection site in adults and children but is not commonly used for subcutaneous injections. Its depth and tissue composition make it less suitable for subcutaneous administration.

D. Abdomen: The abdomen is a recommended site for subcutaneous injections because it has a layer of subcutaneous fat that allows for consistent absorption. Areas at least 2 inches away from the umbilicus are preferred to avoid irritation and ensure proper medication delivery.