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A nurse is caring for a client with diabetic ketoacidosis (DKA). The client asks why he has this condition. What is the nurse's best answer?

"DKA happens when the body's cells can't respond appropriately to the insulin being produced and blood glucose levels rise."

"DKA is a metabolic disorder generally resulting from getting sick while having diabetes mellitus type 2."

"DKA can only be acquired in a client with diabetes mellitus type 1 who experiences septic shock."

"DKA results from the complete absence of insulin resulting from poorly controlled or undiagnosed diabetes mellitus type 1."

Answer and Explanation

The Correct Answer is D

A. DKA occurs due to a significant deficiency of insulin rather than issues with cell response to insulin. The condition leads to high blood glucose and ketone production because there is not enough insulin to regulate glucose levels effectively.
B. DKA is primarily associated with diabetes mellitus type 1, not type 2. It can occur due to a lack of insulin and is not solely caused by illness, although illness can exacerbate it.
C. DKA is not limited to clients with diabetes mellitus type 1 who experience septic shock. It can occur in anyone with type 1 diabetes due to severe insulin deficiency, though septic shock can complicate the condition.
D. DKA results from a complete absence of insulin, which is characteristic of poorly controlled or undiagnosed diabetes mellitus type 1. This insulin deficiency leads to elevated blood glucose levels and ketone formation.

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Correct Answer is C

Explanation

A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.

A. Clay-colored stools B. Tenderness in the left upper abdomen C. Ecchymosis of the extremities D. Straw-colored urine

Correct Answer is A

Explanation

A. Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
B. Tenderness in the left upper abdomen is more commonly associated with issues such as splenic or gastric problems rather than a bile duct obstruction.
C. Ecchymosis of the extremities is not typically associated with bile duct obstruction. It might indicate other issues such as bleeding disorders.
D. Straw-colored urine is not indicative of bile duct obstruction; typically, the urine would appear darker due to elevated bilirubin levels from bile duct obstruction.

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A nurse is caring for a client with diabetic ketoacidosis (DKA). The client asks why he has this condition. What is the nurse's best answer?

Nursing Test Bank

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