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. Loss of hair on the lower extremities can be a common sign of chronic PAD, indicating reduced blood
flow. While it’s an important observation, it is not an immediate concern.
B. Cold legs can indicate poor blood flow, which is a significant concern in PAD. The use of a heating pad can pose a risk of burns due to impaired sensation, especially in clients with poor circulation. This statement warrants immediate intervention, as the nurse should educate the client against using heat sources that can cause injury and assess the client's circulation and potential complications.
C. This describes claudication, a common symptom of PAD, where pain occurs in the legs due to inadequate blood flow during physical activity. While it indicates worsening symptoms of PAD, it is not an immediate emergency.
D. Reddish discoloration (rubor) when the legs are dependent can indicate blood pooling due to decreased venous return or arterial insufficiency. While this observation is significant and requires monitoring, it is not as urgent as the concern related to using a heating pad.

A. Dextrose 5% 0.45% Normal Saline IV B. Oxygen by nasal cannula C. 0.9% saline solution IV D. Administration of Glucagon

Correct Answer is C

Explanation

A. While D5 0.45% NS contains dextrose, it is not suitable as an initial treatment in HHS because patients are often hyperglycemic. Starting with dextrose can worsen hyperglycemia.
B. Although providing oxygen may be appropriate if the client shows signs of respiratory distress or hypoxia, it is not the first-line treatment for HHS. The immediate priority is addressing dehydration and hyperglycemia.
C. The initial therapy for HHS involves administering IV fluids, typically starting with 0.9% saline (normal saline). This helps to rapidly rehydrate the client and dilute the high glucose levels in the blood. Correcting dehydration is critical in HHS management.
D. Glucagon is typically used to treat hypoglycemia, not hyperglycemia. In HHS, the patient is hyperglycemic, so administering glucagon would not be appropriate.

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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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