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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 B

Explanation

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

A. Monitor for symptoms of anemia B. Expect an increase in appetite while on the medication C. Rotate the site of the patch application D. Anticipate relief of symptoms in 1-2 weeks

Correct Answer is A

Explanation

A. Monitoring for symptoms of anemia is essential as methotrexate can cause bone marrow suppression, leading to anemia. The nurse should instruct the client to report symptoms like fatigue, pallor, and shortness of breath.
B. Methotrexate is more likely to cause gastrointestinal side effects like nausea and loss of appetite rather than an increase in appetite.
C. Methotrexate is typically administered orally or by injection, not via a patch, so rotating the site of patch application is not relevant.
D. Relief of symptoms from methotrexate generally takes several weeks to months. It is important to set realistic expectations about the timeline for symptom improvement.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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