A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?
Hypertension
Fruity breath odor
Protruding eyeballs
Decreased urinary output
The Correct Answer is B
A. Hypertension: Clients experiencing diabetic ketoacidosis (DKA) are more likely to present with hypotension rather than hypertension due to dehydration caused by osmotic diuresis. Volume depletion significantly lowers blood pressure rather than raising it in the setting of DKA.
B. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of DKA. It results from the accumulation of ketones, particularly acetone, in the blood, which the body attempts to eliminate through the lungs, giving the breath its characteristic sweet or fruity smell.
C. Protruding eyeballs: Protruding eyeballs, or exophthalmos, are associated with hyperthyroidism, particularly Graves' disease, not with diabetic ketoacidosis. DKA affects metabolic and acid-base balance but does not cause changes to eye appearance or positioning.
D. Decreased urinary output: In the early stages of DKA, clients usually experience increased urinary output (polyuria) due to osmotic diuresis from hyperglycemia. Decreased output may occur only in the later stages when severe dehydration and kidney compromise develop, but it is not an early expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Perfectionistic: Perfectionism is more characteristic of obsessive-compulsive personality disorder, where individuals are overly focused on order, control, and achieving flawless standards. Clients with dependent personality disorder are more focused on relying on others for decision-making rather than striving for perfection.
B. Reclusive: Being reclusive, or socially withdrawn, is a common feature of avoidant personality disorder, not dependent personality disorder. Clients with dependent personality disorder typically seek out and maintain close relationships because they have an intense fear of being alone and unable to care for themselves.
C. Impulsive: Impulsivity is commonly associated with borderline personality disorder, where individuals act without considering consequences. Clients with dependent personality disorder tend to be cautious and overly reliant on others for guidance and approval, rather than acting impulsively on their own.
D. Submissive: Submissiveness is a hallmark of dependent personality disorder. Clients demonstrate extreme dependency on others for emotional and decision-making support, often avoiding disagreement and putting others' needs above their own to maintain relationships and avoid abandonment.
Correct Answer is B
Explanation
A. Leg cramps: Leg cramps are a common and expected discomfort during the later stages of pregnancy. They usually result from changes in circulation, pressure from the growing uterus, or altered calcium and magnesium levels.
B. Blurred vision: Blurred vision is a concerning finding in pregnancy as it can be a sign of preeclampsia, a serious hypertensive disorder that poses risks to both the mother and fetus. It requires immediate evaluation by the provider.
C. Urinary frequency: Urinary frequency is a common symptom in late pregnancy due to the pressure of the enlarging uterus on the bladder. It is typically expected unless accompanied by signs of infection.
D. Gingivitis: Gingivitis can occur during pregnancy due to hormonal changes that affect gum tissue. While it should be managed with good oral hygiene, it is not an urgent concern requiring immediate reporting.
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