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."

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.

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Correct Answer is A

Explanation

A. "Encourage your child to avoid sharing hats with other children." Lice are primarily transmitted through direct head-to-head contact, not by sharing hats or other items.
B. "Lice can jump from one child to another." Lice cannot jump; they crawl from one person to another during direct contact.
C. "Lice do not survive away from the host." Lice can survive away from a host for a limited period (usually less than a day) but not for extended periods.
D. "Washing your child's hair daily will prevent lice." While good hygiene is important, washing hair daily does not necessarily prevent lice infestations.

A. "Give your infant an oral rehydration solution." B. "You might want to try switching to a different formula." C. "Bring your infant into the clinic today to be seen." D. "Burp your child more frequently during feedings."

Correct Answer is C

Explanation

A. "Give your infant an oral rehydration solution." While rehydration is important, projectile vomiting could indicate a more serious underlying issue that needs medical evaluation.
B. "You might want to try switching to a different formula." Formula intolerance is less likely to cause projectile vomiting. A change in formula should not be suggested without ruling out more serious conditions first.
C. "Bring your infant into the clinic today to be seen." Projectile vomiting in an infant, especially when followed by hunger, can indicate pyloric stenosis, a condition that requires prompt medical evaluation. The infant should be seen by a healthcare provider to determine the cause and initiate appropriate treatment.
D. "Burp your child more frequently during feedings." Burping can help with regular gas and minor feeding issues, but it is unlikely to resolve projectile vomiting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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