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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

A.

Skin turgor

B.

Urine ketones

C.

Blood pH greater than expected reference range

D.

Blood glucose greater than expected reference range

E.

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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Related Questions

Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

Correct Answer is B

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

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