A client who is receiving metformin develops lactic acidosis. When planning the care for this client, which nursing diagnosis would the nurse most likely identify?
A) Ineffective Breathing Pattern
B) Risk for Fluid Volume Deficit
C) Acute Confusion
D) Anxiety
Ans: A
Feedback:
When taking metformin, the patient is at risk for lactic acidosis manifested by unexplained hyperventilation, myalgia, malaise, GI symptoms, or unusual somnolence. Thus, a nursing diagnosis of Ineffective Breathing Pattern would be most likely. There are no problems with fluid balance. Acute Confusion would be appropriate if the client was experiencing hypoglycemia. Anxiety would be appropriate for a client who is newly diagnosed with diabetes and having difficulty accepting the diagnosis.
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