A nurse is caring for a client in the emergency department.

Exhibits
For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
Assessment Findings: DKA /HHS

Skin turgor

Urine ketones

Blood pH greater than expected reference range

Blood glucose greater than expected reference range

Creatinine greater than expected reference range

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

A)   Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS.
B)   The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin.
C)   A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.
D)   A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS.
E)   An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

A) An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B) Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C) A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D) A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E) Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F) A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.

A. Hypotension B. Respiratory alkalosis C. Septic shock D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

Correct Answer is ["A","D","E","F"]

Explanation

A) DKA can lead to several complications, including hypotension, which is indicated by the client's low blood pressure reading of 96/65 mm Hg.
B) Respiratory alkalosis is less likely because DKA typically leads to metabolic acidosis, as indicated by the low pH of 7.30.
C) DKA does not result in septic shock but it instead causes hypovolemic shock in case of severe dehydration.
D) Cardiac arrhythmias can occur due to the electrolyte imbalances, as evidenced by the high potassium level of 5.5 mEq/L.
E) Renal failure is another potential complication, suggested by the elevated creatinine level of 1.7 mg/dL. The client's hyperglycemia and dehydration can stress the kidneys, potentially leading to acute kidney injury or renal failure.
F) Cerebral edema is a less common but severe complication of DKA, especially in children and adolescents, and should be considered given the client's symptoms of frequent urination and extreme thirst. It results from over-hydration of the client.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["A","D","E","F"]

Explanation

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