The nurse is caring for a 22-year-old female patient who is brought to the emergency department with a new onset of blurred vision and headache. Use the chart to answer the questions.
The nurse recognizes the patient is demonstrating signs of diabetic ketoacidosis (DKA). Which findings support this recognition? Select all that apply.
(Select All that Apply.)
Acetone breath and respiratory pattern
Blurred vision and headache
Nausea and vomiting
History of type 1 DM Appendix removal at age 7
Weekend alcohol ingestion
Tachycardia and hypotension
Insulin pump turned off
Correct Answer : A,C,F,G
A. Acetone breath, characterized by a fruity or acetone-like odor on the patient's breath, is a classic sign of DKA. In addition, Kussmaul respirations, which are deep and labored breathing patterns, can occur as the body attempts to compensate for metabolic acidosis in DKA.
C. Nausea and vomiting are common symptoms of DKA and can occur due to metabolic acidosis, electrolyte imbalances, and gastrointestinal disturbances associated with the condition.
F. Tachycardia and hypotension are signs of hemodynamic instability, which can occur in severe cases of DKA due to dehydration, electrolyte imbalances, and the systemic effects of metabolic acidosis.
G. Turning off an insulin pump can lead to insulin deficiency, which is a precipitating factor for DKA, particularly in patients with type 1 diabetes who rely on continuous insulin therapy. This finding is consistent with the development of DKA.
B. Blurred vision and headache can be symptoms of DKA, although they are not specific to this condition. Elevated blood glucose levels and dehydration associated with DKA can lead to osmotic diuresis and subsequent fluid shifts, which may manifest as headache and visual disturbances.
D. A history of type 1 diabetes mellitus (DM) predisposes the patient to DKA but the history of appendix removal at age 7 is not directly relevant to the current presentation of DKA.
E. Alcohol ingestion can contribute to the development of DKA by inhibiting gluconeogenesis and promoting ketoacidosis, particularly if the patient is not consuming adequate carbohydrates and insulin. However, it is not a direct sign of DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Medical nutrition therapy for diabetes involves creating a well-balanced, individualized meal plan that meets the patient's nutritional needs while helping to manage blood glucose levels. This approach can be healthy for the entire family and does not require separate meals or special foods. It promotes overall healthy eating habits that everyone can benefit from.
A. Low-carbohydrate diets may be considered for some patients but the emphasis of a diabetic diet is not necessarily on high-protein intake. Instead, the focus is on balanced meals that include appropriate amounts of carbohydrates, proteins, and fats.
B. People with diabetes do not require special foods; rather, they need to make healthier choices from the foods available. The emphasis is on a balanced diet that can include regular foods, with modifications to portion sizes and meal timing to manage blood glucose levels effectively.
D. It is not necessary to completely avoid sugars and fats; rather, the focus should be on moderating intake and choosing healthier options. For example, limiting added sugars and unhealthy fats (like trans fats and saturated fats) is important, but healthy fats (such as those from nuts, seeds, and avocados) can be part of a balanced diet.
Correct Answer is C
Explanation
C. Raisins are a source of carbohydrates, particularly simple sugars like glucose and fructose, which can quickly raise blood sugar levels during an episode of hypoglycemia. However, they do not contain protein, which can help sustain blood sugar levels over time. Raisins may provide a rapid increase in blood sugar but may not be as effective at preventing subsequent episodes of hypoglycemia.
A. Cheese is a source of protein and contains very little carbohydrate. While protein can help stabilize blood sugar levels, it may not provide a rapid increase in blood sugar during an episode of hypoglycemia. Cheese alone may not be the most effective choice for treating low blood sugar promptly.
B. Beef jerky is primarily a source of protein and may not contain enough carbohydrates to quickly raise blood sugar levels during an episode of hypoglycemia. While protein can help stabilize blood sugar over time, it may not provide the rapid increase in blood sugar needed to address acute hypoglycemia.
D. Chocolate, especially dark chocolate with a high cocoa content, contains carbohydrates in the form of sugar and fat. While it can quickly raise blood sugar levels due to its sugar content, it may not provide sustained energy due to its low protein content.
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