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?
"I will report changes in breathing or signs of confusion."
"I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."
"I will notify the doctor if his temperature is not controlled with acetaminophen."
"I will continue to check his blood sugar two times every day."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sun exposure: Sun exposure typically causes sunburn rather than tiny pinhead-sized papules.
B. Allergic reaction: Allergic reactions often present with different types of lesions or hives, not typically tiny papules.
C. Infection: Infections might cause different types of lesions or pustules rather than the described tiny papules.
D. Heat and moisture: Heat rash (miliaria) results from blocked sweat ducts, leading to tiny red papules due to overheating and trapped sweat, commonly occurring in areas like the neck and axilla.
Correct Answer is A
Explanation
A. Reports of scalp itchiness: Itchiness of the scalp is a common symptom of pediculosis capitis (head lice), caused by the allergic reaction to lice bites. This should alert the nurse to the possibility of head lice and warrant further examination.
B. Patches of baldness: While bald patches can be seen in certain conditions like alopecia areata, they are not typically associated with pediculosis capitis.
C. Dry patches on the scalp: Dry patches may indicate a condition like seborrheic dermatitis or psoriasis, but they are not indicative of pediculosis capitis.
D. Blisters on the scalp: Blisters are more likely associated with skin infections or conditions like impetigo, not pediculosis capitis.
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