An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
Skipped eating lunch.
Incorrectly administered too much insulin.
Had a cold and ear infection for the past two days.
Ate an extra peanut butter sandwich before gym class.
The Correct Answer is B
A) Incorrect- While missed meals can contribute to glucose fluctuations, the abrupt onset of diabetic ketoacidosis (DKA) suggests a more immediate cause, such as insulin-related factors.
B) Correct- Diabetic ketoacidosis (DKA) occurs due to a lack of sufficient insulin, resulting in the body breaking down fat for energy and producing ketones. While all the options can contribute to DKA, the most likely cause in this scenario is administering too much insulin. This can lead to a rapid drop in blood glucose levels, causing the body to initiate ketone production for energy.
C) Incorrect- While infections can contribute to insulin resistance, they are not the most common cause of the rapid development of diabetic ketoacidosis (DKA) seen in this scenario.
D) Incorrect- Eating extra food would likely lead to higher glucose levels but wouldn't cause the rapid and severe ketone production characteristic of diabetic ketoacidosis (DKA).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- reapplying a sterile non-adhesive dressing is not enough to address the infection.
The nurse should also clean the wound, apply topical antimicrobial agents, and change the dressing regularly.
B) Incorrect- limiting visitors to immediate family only is not a sufficient infection control measure. The nurse should also use standard precautions, such as wearing gloves, gowns, masks,
and eye protection, and educate the visitors about hand hygiene and proper disposal of contaminated items.
C) Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response.
D) Incorrect- requesting a nutrition consult is not a priority action. While nutrition is important for wound healing, it does not directly affect the infection. The nurse should first administer antibiotics and then assess the client's nutritional status and needs.
Correct Answer is ["A","C","D"]
Explanation
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of fluid volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance systems that may indicate fluid overloads, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.
The other options are not correct because:
B. Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.
E. Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle weakness is not a specific sign of fluid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.
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