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 B

Explanation

Choice A rationale

Susceptible host pertains to the individual's vulnerability to an infectious agent, but handwashing targets the mode of transmission rather than addressing susceptibility or the infectious agent directly.

Choice B rationale

Handwashing interrupts the mode of transmission, preventing pathogens from reaching a portal of entry. This action disrupts the chain of infection and reduces pathogen spread effectively.

Choice C rationale

The infectious agent and reservoir focus on pathogen origination rather than its transfer. Handwashing reduces spread but does not directly address pathogen survival within reservoirs.

Choice D rationale

Portal of exit involves the pathogen leaving the host's body, not its transfer. Handwashing reduces pathogen transmission, specifically addressing its ability to reach a new host.

A. The client will exhibit no further episodes of short-term memory loss. B. The client will be able to return to their construction job in three weeks. C. The client will be emotionally stable and display pre-injury personality traits. D. The client will demonstrate consistent adherence to prescribed medications.

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. .

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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?

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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?