The nurse's next steps would be to administer additional oxygen, keep an eye on the patient's vital signs, and transport him or her to the emergency department.
An emergency department (ED) is a type of medical facility that specialises in providing acute care to patients who arrive without an appointment, either on their own volition or through ambulance. A quick and thorough assessment of a patient's injuries is followed by the creation of a patient care plan, which is primarily the responsibility of the emergency room nurse. Bone setting, blood transfusions, wound care, medication administration, and many other tasks are typical duties.
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a client presents to the ed in shock. at what point in shock does the nurse know that metabolic acidosis is going to occur?
Answer:
decompensation
Explanation:
As compensatory mechanisms fail, the decompensation stage starts. The patient's condition worsens, leading to cardiovascular abnormalities, coagulation issues, and cellular hypoxia. Pyruvic and lactic acids rise as the energy supply falls short of the demand, resulting in metabolic acidosis.
a nurse is preparing a presentation for a group of older adults about health promotion. which statistic would the nurse need to keep in mind about this group?
Geriatric nursing tackles the socioeconomic, psychological, developmental, and physiological aspects.
What part does the nurse play in treating patients with chronic illnesses?In routine follow-up visits, nurses are in charge of regularly monitoring patients with chronic conditions and analysing both the general health situation and behaviour related to health [40]. They create self-management techniques with clients and their families based on this.
What do elderly individuals' nursing interventions entail?Among the nursing interventions for the elderly or family members are: the provision of medical care, including both intensive care and routine care such as feeding, bathing, range of motion, and turning. allowing the elder to take care of their own personal hygiene and grooming. carrying out medical procedures and treatments in accordance with a doctor's orders.
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a child is hospitalized with nephrotic syndrome. which measurement is best for the nurse to determine the child's edema?
Pallor, edema, anorexia, and proteinuria are among the assessment results that the nurse should be prepared to see. Also, the nurse should keep checking the eye to measure the child's edema.
How nephrotic syndrome causes edema in children?The term "nephrotic syndrome" refers to a kidney disorder in which an excessive amount of protein is excreted in the urine due to damaged renal blood vessels. Nephrotic syndrome typically results from damaged glomeruli that permit excessive protein leakage from blood into urine.
Edema is a term for swelling in the body tissues brought on by an accumulation of fluid; it most frequently affects the face, eyelids, feet, ankles, and abdomen. The loss of albumin through the urine and too much sodium are the two main causes of edema.
The most typical symptom of pediatric nephrotic syndrome is swelling around the eyes.
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client vital signs reported by a licensed practical nurse are axilla temperature 37.4, pulse 90 beats per minute, respiratory rate 19 breaths per minute, and blood pressure 86 over 56 millimeters of mercury. what should the nurse check again?
The nurse should check the pulse rate and the axillary temperature again.
Between 96.6° (35.9° C) to 98° F (36.7° C) is considered a normal axillary temperature. Ordinarily, the oral (by mouth) temperature is one degree higher than the typical axillary temperature. For every degree of increase in temperature, the heart rate rises by around 10 beats per minute to accommodate increasing metabolic demands and counteract peripheral dilating effects. Thus, it has become 90 beats per minute because of rhe rise in temperature. To ensure this, the nurse should check the pulse rate or the axillary temperature again.
When a vital sign is abnormal, repeat the measurement to be sure it was taken accurately with the right tools for the patient. The patient's prescription history and history of recent over-the-counter medication use can be used to explain some abnormal vital signs or reveal concealed abnormalities.
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the older adult with diabetes mellitus may present manifestations of hypoglycemia that differ from the classic symptoms of tachycardia, restlessness, and anxiety. what symptom might indicate hypoglycemia in the older adult?
The older adult with diabetes mellitus may present manifestations of hypoglycemia and anxiety. Confusion symptom might indicate hypoglycemia in the older adult
When the amount of sugar (glucose) in your blood falls too low, the condition is known as low blood sugar, commonly referred to as hypoglycaemia or a "hypo." It mostly affects diabetics, anxiety particularly if they use insulin. If not treated right away, that differ from the classic symptoms of tachycardia, restlessness, low blood sugar hypoglycaemia can be dangerous, but you can usually anxiety take care of it on your own.
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which clinicalmanifestations would be typical in an individual with pernicious anemia ataxia
Methylmalonic acid (MMA) levels increase in pernicious anemia patients. Increased levels of MMA and homocysteine promote myelin degradation, which results in neurologic impairments such anemia ataxia and neuropathy.
What types of clinical signs would typically be present in someone with pernicious anemia?Fatigue, weakness, waxy pallor, shortness of breath, rapid heartbeat, shaky stride, smooth tongue, gastrointestinal disorders, and neurological issues are all signs of pernicious anemia. Affected individuals frequently experience memory loss, depression, and weight loss.
What has pernicious anemia as an association?Pernicious anemia is frequently brought on by: An autoimmune condition known as atrophic gastritis causes a weakened stomach lining by having your immune system attack the cells in your stomach lining that produce the intrinsic factor protein.
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for the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. the client does not seem to be responding to the drug and is now lying awake at night. what is the most likely explanation?
The majority of sedative-hypnotic drugs start to lose their effectiveness after one to two weeks of usage. Even if the majority of sedative-hypnotic medications let you sleep deeply for a few nights.
A customer is not a client.Since there are two separate categories of customers, a person who makes use of a company's products or services is referred to as a user rather than a client. As contrast to consumers who usually purchase products, customers purchase solutions and guidance.
Would you provide an illustration of a specific customer type?Anyone who pays for goods or services is referred to as a customer. Customers might be businesses and other institutions. Clients do not have a connection or agreement with the vendor, in contrast to customers who frequently do.
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which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement?
People of all ages, including children, are susceptible to systemic lupus erythematous . However, the largest risk of getting SLE is among women who are of childbearing age (15 to 44 years). Women are harmed much more than males, regardless of age (estimates range from 4 to 12 women for every 1 man).
For a client who might have rheumatoid arthritis, which blood result would the nurse review?We do the following laboratory tests, which, if positive and/or high, support the diagnosis: Rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) testing are both done when a patient is first being assessed for RA.
What does systemic lupus erythematosus look like clinically?Different systemic manifestations may be present in SLE patients. Fever, malaise, arthralgias, myalgias, headache, and other general symptoms.
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which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident?
When the nurse places a stomach tube and arranges for diagnostic tests for a patient who suffered injuries in a bus accident, focused adjuncts are being carried out.
What is a gastric tube?In individuals with IC, gastric tubes are used to either supply food and medicine or to drain gastric content (stomach pumping). The tube ought to be in the stomach and have gone through the heart. This implies that the tube must be visible on chest X-rays down to the diaphragm, ideally deeper to prevent dislocation. It might be challenging to determine whether the tube is in the stomach occasionally due to image quality. An extra, more detailed abdominal imaging and, in certain cases, the injection of tiny volumes of contrast fluid through the tube, may be helpful in these circumstances.
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a terminally ill client is being cared for at home and receiving hospice care. the hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. which sign would the nurse include in this education plan?
Difficulty in swallowing is the sign that the nurse would include in the education plan.
What is a Hospice care?
The goal of hospice care is to improve the lives of people who are suffering from an incurable illness. Hospices care for patients from the time their illness is diagnosed as terminal until the end of their life, however long that may be. That does not imply that hospice care must be continuous.
Hospice care focuses on the care, comfort, and quality of life of a person who is nearing the end of life from a serious illness. It may become impossible to cure a serious illness at some point, or a patient may refuse certain treatments. Hospice is intended for situations like this.
Hospice care is a type of palliative care that is geared toward the terminally ill.
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the nurse is assessing a client admitted with a deep vein thrombosis with an elevated red blood cell count. the admitting diagnosis is polycythemia vera. what is the hallmark clinical sign of pv?
Answer:
splenomegaly
Explanation:
a child who has been in good health has a platelet count of 45,000/mm3, petechiae, and excessive bruising that covers the body. the nurse is aware that these signs are clinical manifestations of which disease?
Clinical signs of immune thrombocytopenic purpura (ITP), which is caused by low platelets, include excessive bruising and petechiae, particularly on the gums and mucous membranes in a kid who is otherwise healthy.
Pallor, lethargy, headaches, dizziness, and a history of an upper respiratory infection are some of the clinical signs of erythroblastopenia. Clinical signs of von Willebrand diseases include nosebleeds, prolonged bleeding from incisions, and excessive bleeding following trauma or surgery. The clinical symptom of hemophilia is bleeding, which is caused by a lack of the normal factor activity required for blood clotting. The clinical signs of ITP, which are caused by low platelets, include excessive bruising & petechiae, especially on the gums and mucous membranes in a kid who is otherwise healthy. Although the cause of ITP is uncertain, it is thought to be an inflammatory process.
(A child who has been in good health has a platelet count of 45,000/mm3, petechiae, and excessive bruising that covers the body. The nurse is aware that these signs are clinical manifestations of
a. a.Erythroblastopenia
b. b.von Willebrand disease
c. c.Hemophilia
d. d.Immune thrombocytopenic purpura (ITP))
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a facility refuses to let a resident administer their own medication even though an assessment indicates they are capable of doing so. which right does this violate?
Residents who are able to administer their prescriptions on their own without help should be encouraged to do so.
What actions can organizations take to encourage residents to take charge of their own lives?Tell them everything you know about your health. A resident has the following rights on the most recent Medicare and Medicaid compliance rating of a facility: the survey report can be seen.
How can you promote active involvement in care?One strategy to enable the service user to actively participate is to involve them in the planning and execution of their own care and support. By removing any barriers to communication, they should be able to express their preferences and decide how and when their care will be provided.
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the nurse is caring for a 6-year-old child with acute glomerulonephritis. when reviewing the client's laboratory results, which result is most important to review with the health care provider?
Blood pressure 136/84 is the correct option that needs to be checked by the health care advisor.
What is Glomerulonephritis?
Glomerulonephritis is an inflammation of the small filters of the kidneys (gloe-MER-u-loe-nuh-FRY-tis) (glomeruli). Urine is the body's method of excreting the extra fluid and waste that glomeruli (gloe-MER-u-lie) remove from the bloodstream. Glomerulonephritis can develop gradually or quickly (acutely) (chronic).
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when describing the action of barbiturates and barbiturate-like agents in the control of seizures, what would the nurse include?
The cerebral cortex is depressed, cerebellar function is changed, and motor nerve output is decreased by barbiturates and medicines of the barbiturate class, which also block impulse conduction in the ascending (RAS).
Barbiturates are helpful medications for the management of epilepsy. The negative systemic consequences are not severe. The presence of cognitive and behavioural issues is the key limiting factor.
What effects do barbiturates have on seizures?
The central nervous system's activity is suppressed by a class of medications known as barbiturate anticonvulsants, which are produced from barbituric acid. GABA is an inhibitory neurotransmitter that is enhanced by barbiturate anticonvulsants. This prevents the onset of discharge that would initiate the seizure.
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after each feeding, a 3-day-old newborn is spitting up large amounts of a non-dairy based newborn formula. the pediatric healthcare provider changes the neonate's formula to a soy protein isolate based infant formula. what information should the nurse provide to the mother about the newly prescribed formula?
The prescribed formula is well tolerated by lactose intolerant infants.
What is lactose intolerance ?Your body's insufficient lactase production is typically the cause of lactose intolerance. Your small intestine normally produces lactase, an enzyme that is a protein that triggers a chemical reaction and is used to break down lactose. A lactase deficiency is the result of insufficient lactase production in the body.
The nurse should explain that the soy-based formula, which contains sucrose and is well-tolerated in infants with milk allergies and lactose intolerance, is being substituted for the cow's milk formula because it may be related to the lactose present in it.
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before administering an antihistamine to a patient, it is most important for the nurse to assess the patient for a history of which condition?
Arrhythmias. Because fatal cardiac arrhythmias have been linked to the use of specific antihistamines and medications that lengthen QT intervals, including erythromycin, extra caution should be used when these medications are administered to any patient who has ever experienced an arrhythmia or a prolonged QT interval.
What conditions should not be used with antihistamines?Antihistamines should not be used if you have hypertension, cardiovascular disease, urine retention, or elevated ocular pressure.
Which instruction should a patient who is taking an antihistamine follow?For people ingesting this medication: If necessary, antihistamines can be taken with food, a glass of water, or milk to lessen gastrointestinal irritation. If you're taking this medication in the form of extended-release tablets, swallow the tablets whole. Never chew, break, or crush anything before swallowing.
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the clinic nurse is preparing to explain the concepts of kohlberg's theory of moral development with a parent. the nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level?
The preconventional level provides the reasoning, the child uses external and physical events (such as pleasure and pain) as the source for decisions about moral rightness or wrongness, his standards are based strictly on what will avoid punishment or bring pleasure.
Lawrence Kohlberg was inspired by Jean Piaget’s work on moral judgment to create a stage theory of moral development in childhood.
The theory includes three levels and six stages of moral thinking. Each level includes two stages. The levels are called preconventional morality, conventional morality, and postconventional morality.
Since it was initially proposed, Kohlberg’s theory has been criticized for overemphasizing a Western male perspective on moral reasoning.
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the nurse in a long-term care facility is caring for a newly admitted client who hasa decreased attention span and cannot concentrate. which type of response to sensory deprivation is the client exhibiting?
The client is displaying a form of cognitive response to sensory deprivation.
What is cognitive response?Cognitive reactions are ideas that come to mind as we are listening to someone speak. Decoding a message is not the same as responding cognitively. The term "decoding" describes an entirely other procedure. Decoding involves translating auditory or visual cues back into language. Our unique reactions or ideas to such messages after we have deciphered them are referred to as our cognitive responses. Our cognitive reactions can be in line with the message if we are particularly interested in the subject. Responses that are pertinent to the message concentrate on refuting claims or providing further proof for a particular viewpoint. Our cognitive reactions might not be highly message-relevant if we are not engaged in the subject. In a nutshell, our cognitive reactions are the ideas we have when listening to other people's communications.
Reading, watching television, listening to the radio, and using the internet all trigger cognitive reactions.
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the nurse administers proparacaine hcl (ophthaine) drops to a patient prior to an eye examination. what sign will the nurse look for to determine when the examination can begin?
The nurse will check to see if there is no blink reflex before starting the examination.
What is the purpose of proparacaine hydrochloride ophthalmic solution?Before surgery, certain examinations, or treatments, the eye is numbed using proparacaine eye drops. The eye drops are applied throughout the surgery to minimize pain. The class of drugs known as local anesthetics includes proparacaine. It does this by preventing pain impulses from reaching the nerve terminals in the eye.
In the eye, how long does proparacaine last?Suitable for ophthalmic application, proparacaine hydrochloride ophthalmic solution is a fast-acting local anesthetic. The effects of anesthetic start to take effect after just one drop and last for at least 15 minutes.
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on admission a client reports taking disulfiram as part of their home medications. what would the nurse need to be aware of when coordinating the client's other medications?
As acetaldehyde dehydrogenase is inhibited by disulfiram, many of the side effects of alcohol use are experienced right away.
What impacts the body does disulfiram have?Disulfiram functions by preventing the body from breaking down alcohol. This causes a hazardous alcohol-related chemical to accumulate, which can make patients who consume alcohol while taking this drug very ill.
How soon does disulfiram start to work?In milder situations, the disulfiram-alcohol interaction lasts 30 to 60 minutes; in more severe cases, it lasts several hours or until the alcohol is digested.
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Anthony has secretly been taking anabolic steroids to improve his athletic performance. Which of the following is a side effect that might tip off his friends and teammates that he has been abusing steroids?A) He is no longer aggressive or violent.B) His skin is remarkably free of acne.C) He has noticeably grown breasts.D) His cholesterol levels have never been lower.
Option C is the correct answer.
Anabolic steroids are prescription-only medicines that are sometimes taken without medical advice to increase muscle mass and improve athletic performance.
If used in this way, they can cause serious side effects and addiction.
Anabolic steroids are manufactured drugs that copy the effects of the male hormone testosterone. They have limited medical uses and are not the same as corticosteroids, a different type of steroid drug that's more commonly prescribed.
Side effects include:-
1. reduced sperm count
2. infertility
3. shrunken testicles
4. erectile dysfunction
5. hair loss
6. breast development
7. increased risk of prostate cancer
8. severe acne
9. stomach pain
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the nurse is slowly advancing a nasogastric (ng) tube when the client begins to gasp and is unable to vocalize. which scenario has likely occurred?
The nurse is slowly advancing a nasogastric (ng) tube when the client begins to gasp and is unable to vocalize. The patient's airway contains the NGT.
What is nasogastric tube ?A tube that is put into the stomach through the nose, then down the neck and esophagus. It can be used to remove items from the stomach as well as to administer medications, liquids, and liquid food. Enteral nutrition refers to feeding someone through a nasogastric tube.
The single-lumen Levin and double-lumen Salem's sump NG tubes are the two most widely used varieties. The double-lumen sump tube is suitable for continuous lavage or irrigation of the stomach, whereas the single-lumen tubes are best for decompression. Both can be applied to either goal.
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which communication strategy would be used by the nurse when working with a client experiencing substance withdrawal delirium?
The nurse should employ the following communication techniques when working with this client: helping the customer develop self-control.
What are the four different sorts of communication tactics?Passive, aggressive, passive-aggressive, and forceful are the four fundamental communication styles. It's critical to comprehend each communication method and the reasons behind its utilization.
What is the best illustration of therapeutic dialogue?When the same nurse explains why they are carrying out the tasks and inquires about the patient's concerns or questions, speaks in a friendly and welcoming manner, and conveys through body language that the patient's opinions are respected, that is an example of therapeutic nursing communication.
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on admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on february 15, and that previously her periods were regular. her pregnancy test is positive. this client's expected date of delivery (edd) would be
The top intervention is to monitor bleeding from peripheral locations. The client is displaying placental abruption symptoms. Placental abruptio is associated with the condition known as diffuse intravascular
DIC: What is it?Unusual blood clotting throughout the blood arteries of the body is brought on by the uncommon but deadly disorder known as diffused intravascular coagulation (DIC). Infections or injuries that interfere with the body's normal blood clotting process can cause DIC.
What is the best way to stop intravascular coagulation?Finding and treating the root cause of DIC is the objective. Some examples of supportive therapies are: If there is significant bleeding, plasma infusions may be used to replace blood coagulation components. Heparin is a blood-thinning medication that can be used to stop blood clotting if it is happening a lot.
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a nurse who has incorporated complementary and alternative medicine (cam) into nursing practice is caring for a client in a short-term care facility. which examples of nursing interventions are based on cam? select all that apply.
• The nurse suggests that the client sign up for a yoga class.
• The nurse instructs the patient in meditation.
• The nurse looks into possible immune system boosters for the patient.
In order to reduce CAM client anxiety, the nurse utilizes guided visualization.
The phrase complementary and alternative medicine (CAM) refers to both complimentary therapies (which may be used in conjunction with standard meditation treatments and so complement them) and alternative treatment techniques (not included in the scope of medical care). CAM practices include yoga, meditation, guided imagery, and herbal medicines. Traditional allopathic (biomedicine) treatments include prescribing painkillers and scheduling diagnostic procedures.
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the nurse is assessing the breasts of a caucasian woman who has just been diagnosed with paget disease. what would the nurse expect to find?
The nurse anticipates finding cramping and abdominal pain.
What is the ideal patient position for detecting breast retraction or dimpling?The patient is seated facing the examiner as the breasts are initially visually evaluated. The patient is told to raise their hands above their heads and place them on their hips.
What part of the breast experiences breast cancer cases the most frequently?The glands that produce breast milk are called lobules. Lobular malignancies are tumors that develop here. The milk is transported to the nipple by ducts, which are tiny channels that emerge from the lobules. The most typical place for breast cancer to begin is here.
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which type of pharmacologic therapy does the nurse anticipate administering to a client for treatment of a spastic bladder in order to decrease bladder hyperactivity?
The pharmacologic therapy nurse should anticipate administering to a client for treatment of a spastic bladder in order to decrease bladder hyperactivity is anticholinergic medications.
What is a bladder spasm?A bladder function issue that results in an unexpected urge to urinate.
Although it can happen in men, overactive bladder typically affects women. Risk factors include getting older, diabetes, and an enlarged prostate.
The need to urinate could be difficult to suppress and result in unintentional urine leakage (incontinence). It could be humiliating or restrict activity.
Exercises for the pelvic floor muscles, prescription drugs, and nerve stimulation are some treatments that can lessen or get rid of symptoms.
What triggers bladder spasms?Constipation can result in bladder spasms in addition to OAB and UTIs. excessive use of alcohol or coffee. Several drugs, including furosemide and bethanechol (Urecholine) (Lasix).
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a client will be receiving a bone graft from an unrelated individual. which type of graft does the nurse inform the client that he or she will be receiving?
The nurse needs to inform the client that he or she will be receiving Allograft.
What is allograft ?A tissue allograft is a transplant of tissue from one member of the same species to another. For instance, an allograft that is given to the recipient in an allotransplantation is a liver from one person.
Allografts are utilized in a variety of operations to reduce pain, restore limb function, save lives, and enhance patient quality of life. dental surgery, plastic surgery, neurosurgery, and orthopedics.
Graft fractures (28% and 29% of patients, respectively) and subluxation (32% and 29% of patients, respectively) were the most frequent complications in the proximal and distal allograft groups. The most frequent outcomes (both 23%) in the intercalary allograft group were nonunion and hardware failure.
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when development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (dka), which action should the nurse instruct the client to implement if this sign of dka occur? a. resume normal physical activity b. drink electrolyte fluid replacement c. give a dose of regular insulin per sliding scale d. measure urinary output over 24 hours.
The right response for a client with newly diagnosed type 1 diabetes is (d) measure urine output over a 24-hour period. The nurse should provide the client instructions to implement if this indicator of dka occurs.
What is diabetes ketoacidosis?Diabetic ketoacidosis is a risky and potentially fatal side effect of diabetes. The majority of persons with type 1 diabetes experience DKA. People with type 2 diabetes can also develop DKA. DKA happens when the body doesn't produce enough insulin, which prevents blood sugar from entering your cells to be used as energy. Diabetes has a serious side effect that causes the body to produce too much blood acid (ketones). This syndrome emerges when the body fails to produce adequate amounts of insulin. It could be caused by a disease or an infection. One or more of the symptoms may include thirst, frequent urination, nausea, stomach pain, weakness, and confusion. Hospital treatment may be required to deliver insulin therapy and replenish lost fluid and electrolytes.
What is the most common cause of diabetic ketoacidosis and can you recover from diabetic ketoacidosis or not?Newly diagnosed diabetes, disruptions in insulin therapy, and underlying infections are the most common causes. (Check out Etiology) Clinically, ketoacidosis and severe uncontrolled diabetes are both present in DKA, which calls for rapid insulin therapy and IV fluids.
Introduction A serious and potentially fatal consequence of diabetes mellitus is diabetic ketoacidosis. Patients with diabetic ketoacidosis are anticipated to recover completely in 24 hours with the right care.
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