Question

A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24 mmol/L). Which assessment finding warrants Immediate intervention by the nurse?

a. Muscle stiffness.
b. Abdominal pain.
c. Mental stupor.
d. Fruity breath.

Answer 1

The assessment finding that warrants immediate intervention by the nurse is mental stupor.

Step-by-step explanation:

The assessment finding that warrants immediate intervention by the nurse in this case is mental stupor.

Diabetic ketoacidosis (DKA) is a complication of diabetes where there is a build-up of ketones and acid in the blood. The patient in this scenario is demonstrating Kussmaul breathing (deep, rapid breathing) and has a severe headache along with nausea. A pH level of 7.50 indicates alkalosis, and the presence of fruity breath suggests the presence of acetone in the breath due to ketone production.

However, mental stupor is a concerning symptom that could indicate worsening dehydration and acidosis. It is a sign that the brain is not receiving enough glucose to function properly. Immediate intervention is necessary to address the underlying cause and prevent further complications.