A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?

A. Negative urine ketones: Diabetic ketoacidosis (DKA) is characterized by increased production of ketone bodies due to insulin deficiency and enhanced lipolysis. Ketones accumulate in the blood and spill into the urine, producing positive urine ketone results. The absence of urine ketones does not support the presence of ketoacidosis, as ketosis is a defining metabolic feature.

B. Kussmaul respirations: Kussmaul respirations are deep, rapid breathing patterns that occur as a compensatory response to metabolic acidosis. In DKA, excess ketone production leads to accumulation of hydrogen ions and decreased serum bicarbonate. The respiratory system compensates by increasing ventilation to eliminate carbon dioxide.

C. Hypoglycemia: DKA is associated with hyperglycemia due to insufficient insulin, which prevents glucose from entering cells and leads to elevated serum glucose levels. Hypoglycemia involves low blood glucose and does not trigger the ketone overproduction seen in DKA. The pathophysiology of DKA centers on insulin deficiency and high circulating glucose.

D. Hypertension: Clients with DKA often experience osmotic diuresis from severe hyperglycemia, leading to dehydration and volume depletion. This intravascular fluid loss more commonly results in hypotension rather than elevated blood pressure. The hemodynamic changes in DKA are primarily related to dehydration and electrolyte imbalance.

A. Instruct the client to report the theft to the police: While reporting to law enforcement is an option, the client may feel intimidated or unsafe doing so, and immediate protection and assessment of the situation are more urgent. The nurse’s priority is ensuring safety and initiating appropriate protective services.

B. Report the possible abuse to adult protective services: Financial exploitation is a form of elder abuse. Nurses are mandated reporters and should notify adult protective services to investigate and intervene as needed. This ensures the client’s safety, prevents further exploitation, and connects them with resources for protection and support.

C. Ask the client if there is another family member they can call for financial help: While exploring support systems is important, relying on another family member without assessment may not address potential abuse and does not fulfill the nurse’s legal obligation to report suspected exploitation.

D. Restrict visitation for the client's family until discharge: Restricting visitation may limit contact temporarily, but it does not address the underlying abuse or ensure ongoing protection. Reporting to protective services provides a structured and legal mechanism for safeguarding the client.