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. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.
B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.
C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.
D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.
Correct Answer is C
Explanation
A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.
B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.
C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.
D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.
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