A nurse is assessing a client who has type 1 diabetes mellitus and has a blood glucose level of 550 mg/dL. Which of the following should the nurse assess the client for if diabetic ketoacidosis (DKA) is suspected?
Dizziness
Nervousness
Mental status changes
Cool, clammy skin
The Correct Answer is C
Choice A reason: Dizziness can be a symptom of DKA due to dehydration; however, it is not as specific as mental status changes.
Choice B reason: Nervousness is not a specific symptom of DKA and can be related to high blood glucose levels rather than DKA itself.
Choice C reason: Mental status changes such as confusion or altered consciousness are significant indicators of DKA and require immediate medical atention.
Choice D reason: Cool, clammy skin is not typically associated with DKA; instead, DKA can present with dry skin and mouth due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Pruritus, or severe itching, is a common symptom in patients with ESRD due to the build-up of waste products in the body.
Choice B reason: Slurred speech is not typically associated with ESRD. It may be a symptom of other neurological conditions or could be related to medications or treatments.
Choice C reason: Hypotension can be an expected finding in ESRD due to the fluid shifts and changes in blood volume
that occur during dialysis treatment.
Choice D reason: Bone pain is a known complication of ESRD, often resulting from the mineral and bone disorders that are part of chronic kidney disease-mineral and bone disorder (CKD-MBD).
Choice E reason: Bradypnea, or abnormally slow breathing, may occur in ESRD as a result of metabolic changes affecting the respiratory system.
Correct Answer is C
Explanation
Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.
Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.
Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.
Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.
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