Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?
A. Fruity breath odor
This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.
B. Clammy skin
C. Bounding pulse
D. Elevated blood pressure
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Full Explanation
The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.
Similar Questions
A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an indication that the client is experiencing a crisis?
A. Client reports a decreased appetite
B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.
C. Client expresses an inability to experience pleasure
D. Client reports intermittent depressed mood
Full Explanation
Answer: B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.
A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?
A. Increased appetite
B. Loss of taste
Rationale: External radiation for throat cancer can damage the taste buds and cause loss of taste or altered taste sensation. This can affect the client's nutritional intake and quality of life. The other options are not expected findings of external radiation for throat cancer and could be caused by other factors.
C. Loose stools
D. Bladder infection
Full Explanation
Answer: B. Loss of taste
Rationale: External radiation for throat cancer can damage the taste buds and cause loss of taste or altered taste sensation. This can affect the client's nutritional intake and quality of life. The other options are not expected findings of external radiation for throat cancer and could be caused by other factors.
A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.Which of the following statements by the parent indicates an understanding of the teaching?
A. “I will place my newborn's crib near a heat vent during cold weather."
B. "I will place my newborn face up on a pillow when sleeping."
C. "I will attach the pacifier to my newborn's clothing with a string at bedtime."
D. "I will make sure that I can fit one finger between the mattress and the side of my newborn's crib."
Rationale: The parent should make sure that the mattress fits snugly in the crib and that there are no gaps between the mattress and the side of the crib that could trap the newborn's head or body. This reduces the risk of suffocation or entrapment. The other statements by the parent are incorrect and unsafe practices that could harm the newborn.
Full Explanation
Answer: D. I will make sure that I can fit one finger between the mattress and the side of my newborn's crib.
Rationale: The parent should make sure that the mattress fits snugly in the crib and that there are no gaps between the mattress and the side of the crib that could trap the newborn's head or body. This reduces the risk of suffocation or entrapment. The other statements by the parent are incorrect and unsafe practices that could harm the newborn.