Patient Data.
What are the signs and symptoms of DKA? Select all that apply.
Hyperglycemia.
Ketonuria.
Metabolic acidosis.
Hypokalemia.
Dehydration.
Kussmaul respirations
Correct Answer : A,B,C,E,F
Choice A rationale:
Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise1. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.
Choice B rationale:
Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.
Choice C rationale:
Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis1.
Choice D rationale:
Hypokalemia is not a symptom of DKA. In fact, patients with DKA often have high potassium levels in their blood at presentation because acidosis causes potassium to move from inside the cells into the bloodstream1. However, during treatment for DKA, when insulin is administered and acidosis is corrected, potassium moves back into the cells and can lead to low potassium levels or hypokalemia1.
Choice E rationale:
Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.
Choice F rationale:
Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). This order is questionable because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can potentially increase blood pressure, which could be harmful to a patient with hypertension. Furthermore, NSAIDs can mask the symptoms of infection, which could delay the diagnosis and treatment of serious infections.
Choice B rationale:
Enalapril 10 mg every morning. This order is questionable because enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. However, ACE inhibitors can cause a dry cough, which could exacerbate the patient’s existing cough due to pneumonia. Additionally, ACE inhibitors can potentially cause hyperkalemia (high potassium levels), so it’s important to monitor the patient’s electrolyte levels.
Choice C rationale:
Supplemental oxygen 10 L/min via nasal cannula. This order is questionable because a high flow rate of oxygen can potentially cause oxygen toxicity or hyperoxia, which can lead to cellular damage. The typical flow rate for a nasal cannula is between 1-6 L/min. A flow rate of 10 L/min may be too high for this patient, especially without a specified target SpO2 range.
Choice D rationale:
Continuous pulse oximetry. This order is appropriate because it allows for continuous monitoring of the patient’s oxygen saturation levels, which is crucial in a patient with pneumonia and shortness of breath.
Choice E rationale:
Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. This order is appropriate because these tests can help monitor the patient’s overall health status and response to treatment.
Choice F rationale:
Admit to the medical floor. This order is appropriate because the patient requires hospitalization for treatment and monitoring due to his pneumonia.
Choice G rationale:
Vital signs every 4 hours. This order is appropriate because it allows for regular monitoring of the patient’s vital signs, which can help detect any changes in his condition.
Choice H rationale:
Chest x-ray now. This order is appropriate because a chest x-ray can help confirm the diagnosis of pneumonia and assess its severity.
Choice I rationale:
Sputum culture and sensitivity. This order is appropriate because it can help identify the specific organism causing the pneumonia and determine its antibiotic sensitivity, which can guide antibiotic therapy.
Choice J rationale:
Levofloxacin 500 mg intravenously every 24 hours. This order is appropriate because levofloxacin is a broad-spectrum antibiotic commonly used to treat pneumonia.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale:
Provide a safe and calm environment for the client during a panic attack. Creating a safe and calm environment is crucial during a panic attack. It can help the client feel more secure and reduce the intensity and duration of the panic attack.
Choice B rationale:
Use therapeutic communication skills to establish rapport and trust with the client. Therapeutic communication is essential for clients with panic disorder. It helps establish a trusting relationship between the nurse and the client, which is crucial for effective treatment and support.
Choice C rationale:
Educate the client about panic disorder and its treatment options. Educating the client about their condition and available treatment options empowers them to make informed decisions about their care. It also reduces anxiety and fear associated with the disorder.
Choice D rationale:
Encourage the client to participate in cognitive-behavioral therapy (CBT). Cognitive-behavioral therapy is a well-established and effective treatment for panic disorder. Encouraging the client to participate in CBT can help them develop coping strategies and manage their symptoms.
Choice E rationale:
Refer the client to self-help groups for peer support and education. Self-help groups can provide valuable peer support and education to individuals with panic disorder. Being part of such a group can reduce feelings of isolation and provide practical advice for managing the condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.