The nurse is concerned that a school-age client has undiagnosed type 1 diabetes mellitus and is experiencing diabetic ketoacidosis (DKA). What did the nurse assess in the client to come to this conclusion?
Select all that apply.
A) Blurred vision
B) Irregular heartbeat
C) Sunken eye sockets
D) Sluggish bowel sounds
E) Dry mucous membranes
Answer: A, B, C, E
The clinical manifestations of all forms of diabetes in children include blurred vision. The clinical hallmarks of diabetic ketoacidosis are dehydration and electrolyte imbalance. An irregular heartbeat can occur with an electrolyte imbalance. Sunken eye sockets and dry mucous membranes are seen in dehydration. Sluggish bowel sounds are not an indication of diabetes or diabetic ketoacidosis.
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a. 85 mcg/hr b. 0.8 mg/hr c. 85 mL/hr d. 85 mg/hr
After completing nutritional screening with a client, the nurse identifies the diagnosis of imbalanced nutrition: less than body requirements. What should the nurse identify as a realistic goal for this client?
a. Increase fat in the diet 2b. Replace sweets with high-protein foods c. Increase weight by one pound per week d. Decrease physical activity to 2 hours per week
When caring for an elderly client, the nurse should plan interventions based on the understanding that the elderly often
a. are frequently confused on admission. b. are particularly at risk for confusion in the hospital. c. do not seem bothered by changes in routines. d. have an intact recent memory.
Your client is lying on a bed with plastic sheets. What potential nursing diagnosis does this knowledge suggest?
1. Impaired skin integrity 2. Risk for impaired skin integrity 3. Disuse syndrome 4. Risk for disuse syndrome