What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

mental status = lethargic, oriented X 3 but unsure of reason for presenting for care

arterial blood gas pH 7.47/ pCO2-40/HCO3-33/ pa02 = 95

arterial blood gas pH=7.31/pCO2-34/HCO3-17/pa02=98

heart rate=52, regular

respiratory rate = 31, deep

Answer and Explanation

Correct Answer : A,C,E

A.   Lethargy can occur in DKA due to the effects of hyperglycemia, acidosis, and dehydration. Even if the client is oriented, confusion about the reason for care suggests an altered mental state, which can be common in DKA.
B.   This ABG indicates alkalosis (pH > 7.45), which is not typical for DKA. In DKA, we would expect a lower pH (acidosis). This set of values does not align with the expected clinical picture of DKA.
C.   This ABG shows a pH of 7.31, indicating acidosis. The low HCO3 (17) supports metabolic acidosis, which is characteristic of DKA. This finding is consistent with the expected laboratory results in a patient experiencing DKA.
D.   A heart rate of 52 (bradycardia) is not a common finding in DKA. In fact, tachycardia (elevated heart rate) is typically observed due to dehydration and compensatory mechanisms. Bradycardia would not be expected in this context.
E.   A respiratory rate of 31, particularly if deep (known as Kussmaul respirations), is a classic sign of metabolic acidosis, including DKA. Kussmaul respirations are the body’s attempt to compensate for acidosis by increasing carbon dioxide elimination.

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Correct Answer is B

Explanation

A. While claudication (muscle cramps with exercise) is common in earlier stages of PAD, it typically occurs in stage II. In stage III, pain often occurs at rest rather than with exertion.
B. In stage III PAD, patients often report rest pain, which can manifest as burning pain in the legs or feet, particularly at night when lying down. This is a hallmark symptom of advanced PAD due to inadequate blood flow.
C. While diminished pulses (like +1) can be found in PAD, this finding alone is not specific to stage III. In advanced stages, pulses may be even weaker or absent.
D. Blackened tissue (necrosis or gangrene) indicates a more severe stage (stage IV) of PAD, where there is critical limb ischemia and tissue death due to a lack of blood flow. Stage III may involve severe pain but usually does not have necrosis.

A. Notify the physician since this is a sign of deterioration. B. Offer the client back massage to reduce the pain. C. Place the client in prone position to limit vesicoureteral reflux. D. Offer the client an analgesic if prescribed.

Correct Answer is D

Explanation

A. While costovertebral tenderness is significant and indicates kidney involvement, it is a common symptom of acute pyelonephritis and not necessarily a sign of deterioration. Immediate notification may not be warranted unless other concerning symptoms are present.
B. Although back massage may seem comforting, it is not indicated in this scenario. The kidneys are inflamed, and massage could exacerbate pain or discomfort. It does not address the underlying condition or the pain effectively.
C. The prone position is not typically recommended for clients with pyelonephritis. Instead, the client may be more comfortable in a position that does not put pressure on the kidneys, such as sitting up or lying on their back or side. This intervention does not directly address the pain or comfort of the client.
D. Offering an analgesic is the most appropriate action. Pain management is crucial for the comfort of the client, and an analgesic can help alleviate the discomfort associated with costovertebral tenderness. If the physician has prescribed an analgesic, administering it would be in line with promoting comfort and addressing the client’s needs.

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What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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