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Patient Data.

Exhibits

What are three goals of therapy for this client? Select three that apply.

Correct electrolytes that are out of normal range.

Promote oxygenation to tissues.

Prevent hyperventilation.

Reverse dehydration.

Replace insulin.

Provide respiratory support.

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.

Choice B rationale:

This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.

Choice C rationale:

This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.

Choice D rationale:

This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.

A. Instill 3 mL of normal saline before suctioning. B. Instruct the client to cough as the suction tip is removed. C. Apply a water-soluble lubricant to the catheter. D. Wear protective goggles while performing the procedure. E. Wear protective goggles while performing the procedure.

Correct Answer is D

Explanation

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

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Patient Data. Exhibits What are three goals of therapy for this client? Select three that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

Correct Answer is D

Explanation

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Correct Answer is D

Explanation

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Patient Data.

Exhibits

What are three goals of therapy for this client? Select three that apply.