How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

A.

"I will report changes in breathing or signs of confusion."

B.

"I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."

C.

"I will notify the doctor if his temperature is not controlled with acetaminophen."

D.

"I will continue to check his blood sugar two times every day."

Answer and Explanation

The Correct Answer is D

A. "I will report changes in breathing or signs of confusion." Correct action as changes in breathing or confusion can indicate diabetic ketoacidosis or other serious complications.
B. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."Ensuring adequate fluid intake helps prevent dehydration and helps manage blood sugar levels during illness.
C. "I will notify the doctor if his temperature is not controlled with acetaminophen." Correct action as fever may indicate an infection that needs further medical evaluation and treatment.
D. "I will continue to check his blood sugar two times every day." When a child with diabetes is ill, blood sugar should be monitored more frequently, typically every 3-4 hours, to manage the risk of hyperglycemia or hypoglycemia due to illness.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. Projectile vomiting after feedings: Projectile vomiting after feedings, especially occurring a short time after feeding, is a classic sign of pyloric stenosis due to obstruction at the pylorus.
B. Absent bowel sounds: Absent bowel sounds may occur in more advanced cases of bowel obstruction but are not specific to pyloric stenosis.
C. Increased sodium level: Increased sodium level is not typically associated with pyloric stenosis.
D. Golf ball-size mass over the left quadrant: A palpable mass in the left quadrant is not a typical finding in pyloric stenosis.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

    Immediate priority: The child is febrile (38.9°C) with tachycardia. Fever and low Hgb and platelets suggest possible serious underlying hematologic disorder (e.g., leukemia, bone marrow suppression). Infection is life-threatening in this context. So temperature (fever) should be addressed first. Next concern: The lab values (low Hgb, Hct, platelets) show significant hematologic abnormalities that explain the fatigue, bruising, and petechiae and will guide further treatment (possible transfusion, infection risk management). Incorrect answers:
  • Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
  • Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
  • Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.
  • Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.
  • Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.
  • Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

    • Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

    Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

    Register