A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

Administer 40 ounces of fruit juice.

Administer 15 grams of simple carbohydrates in the form of hard candy.

Administer 50 mL of Dextrose 50% IV push.

Repeat the blood glucose test after 15 minutes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering 40 ounces of fruit juice would result in excessive carbohydrate intake and is inappropriate for treating hypoglycemia. Standard treatment includes 15 grams of carbohydrates or intravenous glucose for severe symptoms.

Choice B rationale

Hard candy provides 15 grams of carbohydrates, suitable for a patient who is alert and able to safely swallow. However, this client exhibits confusion and lethargy, necessitating a quicker, safer IV intervention.

Choice C rationale

Administering Dextrose 50% IV push rapidly raises blood glucose levels, effectively treating hypoglycemia in symptomatic, confused, or unconscious patients. This intervention bypasses the gastrointestinal tract for immediate action.

Choice D rationale

Rechecking glucose after 15 minutes is essential after treatment but does not address acute hypoglycemia. Delaying treatment risks prolonged hypoglycemia, increasing the risk of neuronal injury or further clinical deterioration. .

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Correct Answer is D

Explanation

Choice A rationale

Absence of short-term memory loss may be desirable but depends on the injury's severity and therapy progression. Memory recovery is inconsistent and often impractical as a definitive short-term outcome goal.

Choice B rationale

Resuming construction work is unrealistic within three weeks considering potential cognitive and physical impairments. This task exceeds achievable rehabilitation milestones, emphasizing safety over rapid return to demanding roles.

Choice C rationale

Pre-injury personality traits may not fully return, as emotional and personality changes often result from cerebral insults. Emotional stability is feasible but pre-injury personality restoration is speculative.

Choice D rationale

Medication adherence reflects successful cognitive rehabilitation, supporting long-term health stability by preventing further complications. This outcome is realistic and appropriate for patients recovering from intracranial injuries. .

A. Nitroprusside. B. 3% Normal Saline. C. Furosemide. D. Norepinephrine.

Correct Answer is B

Explanation

Choice A rationale

Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.

Choice B rationale

Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.

Choice C rationale

Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.

Choice D rationale

Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .

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A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?