A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.
Dysrhythmias.
Kussmaul respirations.
Weakness.
Cold, clammy skin.
Correct Answer : B,C,E
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hypocalcemia refers to low levels of calcium in the blood, which can present with symptoms like muscle cramps, numbness, and tingling. However, this choice is not relevant to the patient's symptoms in the scenario.
Choice B rationale:
Hypercalcemia is an electrolyte imbalance characterized by high levels of calcium in the blood. It can lead to ECG changes and symptoms like muscle weakness, confusion, and constipation. However, this is not the correct answer in the given scenario.
Choice C rationale:
The patient's symptoms of ECG changes and muscle weakness are consistent with hyperkalemia. Spironolactone is a potassium-sparing diuretic, and its use can lead to increased potassium levels in the blood (hyperkalemia), which can affect the heart's electrical activity and cause muscle weakness.
Choice D rationale:
Hypokalemia is a condition where there is a low level of potassium in the blood. It can lead to muscle weakness, ECG changes, and other symptoms, but it is not the correct answer in this specific situation involving spironolactone use.
Correct Answer is D
Explanation
Potential Condition.
Based on the provided information, it's challenging to make a definitive diagnosis with the given laboratory results and clinical presentation. The client's symptoms, such as severe abdominal pain, vomiting, dyspnea, yellow sclera, dry mucous membranes, tachycardia, and positive Chvostek and Trousseau signs, suggest a complex clinical picture that requires further investigation and assessment. Action to Take 1: Notify the provider. Rationale: The client's condition appears to be critical and requires immediate medical attention. Notifying the provider will initiate a comprehensive evaluation and potential interventions. Action to Take 2: Withhold medication for diarrhea until the underlying cause is determined. Rationale: Diarrhea can be a symptom of various conditions, and administering medication without a clear diagnosis may mask important clinical information. Parameters to Monitor 1: Serum bicarbonate level.
Rationale:
Monitoring serum bicarbonate levels can help identify potential acid-base imbalances and assess the client's metabolic status, especially given the history of end-stage renal disease. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to assess fluid balance and kidney function, especially in a client with end- stage renal disease and potential electrolyte imbalances.
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