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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) Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B) Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C) Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D) Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.

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.
 

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