The nurse teaches the teenager and parents that the signs of diabetic ketoacidosis (DKA) include which of the following? (Select all that apply.)
1. Tachycardia
2. Abdominal pain
3. Fruity breath odor
4. Change in mental status
5. Rapid, shallow respirations
2. Abdominal pain
3. Fruity breath odor
4. Change in mental status
Rationale:
Abdominal pain is commonly seen with DKA. A fruity breath odor is common when the client is in a state of ketoacidosis. A change in mental state can be associated with DKA. Tachycardia is not a typical symptom of DKA. Respirations are rapid, but deep (Kussmaul's breathing) in DKA.
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When formulating the teaching plan for a client with hyperpituitarism being prepared for transsphenoidal hypophysectomy, the nurse would give priority to
a. alerting the client to the need for constant monitoring after surgery. b. instructing the client to avoid activities such as coughing and sneezing. c. reviewing the clinical manifestations of infection. d. teaching coughing and deep-breathing techniques.
The fiercely independent 90-year-old woman who is recovering from a stroke frequently ambulates without the use of her walker because she says it is ugly and cumbersome. What would be the most effective intervention of the nurse?
a. Allow her to ambulate independently. b. Place a gait belt around her and ambulate when she does. c. Bring her walker to her and remind her that the walker is for her safety. d. Instruct her to use a wheelchair for mobility.
If an intramuscular injection is administered to a child who has Reye's syndrome,the nurse should watch for
1. bleeding at the injection site. 2. infection at the injection site. 3. poor absorption. 4. itching at the injection site.
The educator has reviewed the role of histamine receptors associated with allergic symptoms with a nurse. Which statement made by the nurse indicates further instruction is needed?
A. "H1 receptors are found in the stomach." B. "H1 receptors are responsible for allergic symptoms." C. "H2 receptors increase mucus secretion in the stomach." D. "H2 receptors are responsible for peptic ulcers."