A 5-year-old patient is being treated for diabetic ketoacidosis. The patient's blood glucose is normalizing and acidosis has been partially corrected. The child's mother says, "This is the best rest he has gotten since we arrived yesterday
He hasn't moved in the last 20 minutes.". What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Dim the lights in the room to allow the child and mother to rest.
2. Wake the child and assess for changes in mental status.
3. Discontinue the 0.9NS IV infusion.
4. STAT page the child's health care provider.
5. Check the child's pupillary response.
2,5
Rationale 1: This is not the best intervention for this situation.
Rationale 2: The development of cerebral edema is a complication of DKA therapy. The "resting" noted by the mother may in fact be approaching coma. Assessment is critical.
Rationale 3: Infusion of 0.9NS by IV may help protect the patient from the development of cerebral edema.
Rationale 4: The nurse does not have enough information until assessment is done.
Rationale 5: The development of cerebral edema is a complication of DKA therapy. Brain herniation may occur. The nurse should assess for abnormal neurological signs such as changes in pupillary response.
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