A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Blood glucose level below 40 mg/dL

Malignant hypertension

Cheyne-Stokes breathing

Acetone odor to breath

Answer and Explanation

The Correct Answer is D

A. Blood glucose level below 40 mg/dL: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with blood glucose levels significantly elevated above normal, often exceeding 250 mg/dL. A glucose level below 40 mg/dL would indicate hypoglycemia, which is not a feature of DKA.

B. Malignant hypertension: Malignant hypertension is a condition characterized by extremely high blood pressure and is not directly associated with DKA. DKA primarily involves issues with glucose and acid-base balance rather than hypertension.

C. Cheyne-Stokes breathing: Cheyne-Stokes breathing is a specific pattern of periodic breathing typically seen in severe neurologic conditions or heart failure, not in DKA. DKA is associated with Kussmaul breathing, which is deep and rapid breathing as the body attempts to compensate for metabolic acidosis.

D. Acetone odor to breath: An acetone (fruity) odor to the breath is a classic sign of DKA due to the presence of ketones in the blood and urine. This occurs because the body is breaking down fatty acids for energy, leading to the production of ketones, which are then excreted through the breath and urine.

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Correct Answer is A

Explanation

A. Genetics: Genetics is a non-modifiable risk factor for stroke, meaning it cannot be changed or controlled. A family history of stroke increases an individual's risk due to inherited traits or predispositions.

B. Obesity: Obesity is a modifiable risk factor. Individuals can reduce their risk through diet, exercise, and other lifestyle changes.

C. History of smoking: Smoking is a modifiable risk factor, as individuals can quit smoking to reduce their risk of stroke.

D. History of hypertension: Hypertension is also a modifiable risk factor, as it can be managed and controlled with medication and lifestyle changes.

A. Assess for neck vein distention B. Monitor for postural hypotension C. Assess blood glucose level D. Monitor for an irregular heart rate E. Weigh the client daily

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

Explanation

A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.

B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.

C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.

D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.

E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.

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A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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