A nurse is caring for a patient diagnosed with diabetic ketoacidosis.
Which of the following symptoms should the nurse expect?
Cheyne-Stokes breathing.
Acetone odor to breath.
Blood glucose level below 40 mg/dL.
Malignant hypertension.
The Correct Answer is B
Choice A rationale
Cheyne-Stokes breathing, characterized by a cycle of increasing and decreasing respiratory rate and depth, is not a typical symptom of diabetic ketoacidosis (DKA). DKA is more commonly associated with Kussmaul breathing, which is rapid, deep, and labored.
Choice B rationale
An acetone odor to the breath is a classic symptom of DKA. This is due to the body breaking down fat for energy, which produces ketones. These ketones can cause the breath to smell fruity or like nail polish remover.
Choice C rationale
A blood glucose level below 40 mg/dL is not a symptom of DKA. In fact, DKA is characterized by high blood glucose levels, typically above 250 mg/dL111213.
Choice D rationale
Malignant hypertension is not a typical symptom of DKA. While DKA can cause dehydration and electrolyte imbalances that may affect blood pressure, it does not typically cause malignant hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Moving the client to a room closer to the nurses’ station is an appropriate action to address the safety needs of an older adult client who is becoming increasingly restless and intermittently confused. This allows for closer observation and quicker intervention if needed.
Correct Answer is []
Explanation
Potential Condition:
- B. Type 1 diabetes mellitus
The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.
Actions to Take:
- B. Teach the client about the signs of hyperglycemia.
- D. Assess the client’s feet for sensation.
Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.
Parameters to Monitor:
- B. Blood pressure
- D. Fingerstick blood glucose
Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.
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