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 C
Explanation
A. Apply lotion between toes: Lotion should not be applied between the toes because the moisture can promote fungal infections. Instead, lotion can be applied to the tops and bottoms of the feet to prevent dryness and cracking.
B. Use a heating pad to warm feet: Clients with diabetes often have decreased sensation in their feet and using heating pads can cause burns without them realizing it. Safer methods, like wearing warm socks, should be used to keep feet warm.
C. Apply cotton socks to feet daily: Wearing clean, dry cotton socks daily helps protect the feet, maintain warmth, and absorb moisture, reducing the risk of fungal infections and skin breakdown, which are common concerns for clients with diabetes.
D. Inspect appearance of feet weekly: Clients with diabetes should inspect their feet daily, not weekly. Daily inspection helps catch cuts, blisters, or signs of infection early to prevent serious complications such as ulcers or amputations.
Correct Answer is A
Explanation
A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.
B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.
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