The nurse observes fruity breath in an individual with diabetic ketoacidosis. Which of the following may also be observed?
a. Pallor.
b. Kussmaul's breathing.
c. Bradycardia.
d. Clammy skin.
b
If hyperglycaemia is not corrected, metabolic acidosis occurs, producing vasodilatation and hypotension. Early
manifestations are thirst, anorexia, nausea, vomiting, abdominal pain, muscle cramps, polyuria and drowsiness. Deep rapid
respirations (Kussmaul's breathing) develop in an attempt
to control acidosis. Ketones, produced by the liver as fat,
are broken down instead of glucose (diabetic ketoacidosis),
glucose is excreted in the urine and the breath smells of
ketones (sweet fruity odour).
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A nurse who provides care for a diverse patient population on a busy medical unit has had significant success with the use of ice and heat in the management of patients' pain
The nurse should exercise particular caution when applying cold therapy or heat therapy to a patient who: A) Is unable to communicate or has a cognitive or sensory deficit B) Is simultaneously using a patient-controlled analgesic (PCA) pump C) Consistently rates his or her pain at 8 out of 10 or higher D) Has pain unrelated to observable tissue damage
NOT all health care workers are expected to continue to learn
True False
A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed
While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply
A) Irregular border B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain