A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

Maternal diabetes

Prematurity

Hypothermia

Thrombocytopenia

Anemia

Answer and Explanation

Correct Answer : A,B,C

Rationale:

A. Maternal diabetes: Infants born to diabetic mothers are at increased risk for hypoglycemia due to elevated insulin levels stimulated by maternal hyperglycemia. After birth, the abrupt loss of maternal glucose can lead to a rapid drop in the infant’s blood sugar.

B. Prematurity: Premature infants have limited glycogen stores and immature metabolic systems, making them more susceptible to hypoglycemia. Their inability to effectively regulate glucose levels increases their risk after birth.

C. Hypothermia: Cold stress increases metabolic demands and glucose consumption. As the infant uses more energy to maintain body temperature, blood glucose levels can drop rapidly if not closely monitored and managed.

D. Thrombocytopenia: Low platelet counts may indicate other underlying conditions but are not directly associated with hypoglycemia. It is more relevant to clotting and bleeding risks rather than glucose regulation.

E. Anemia: Anemia affects oxygen-carrying capacity but does not have a direct link to blood glucose control. While it may indicate other health issues, it is not a recognized independent risk factor for neonatal hypoglycemia.

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Correct Answer is C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

A. Client's chief complaint B. Client's job performance history C. Client's relationships with family and friends D. Client's copying nurses words E. Client's statement about their mother F. Client's speech pattern

Correct Answer is ["A","D","E","F"]

Explanation

Rationale:

A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.

B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.

C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.

D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.

E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.

F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.

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A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

Nursing Test Bank

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