A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?
Fever.
Shakiness.
Increased urination.
Thirst.
The Correct Answer is B
Choice A rationale:
Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.
Choice B rationale:
Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.
Choice C rationale:
Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.
Choice D rationale:
Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Choice A rationale:
Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.
Choice B rationale:
Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.
Choice C rationale:
Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.
Choice D rationale:
Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.
Choice E rationale:
Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.
Choice F rationale:
Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.
Correct Answer is D
Explanation
Choice A rationale:
Children who have erythema infectiosum (fifth disease) require short-term antibiotic therapy. Erythema infectiosum, also known as fifth disease, is caused by a virus and does not require antibiotic therapy. It is a self-limiting illness that does not respond to antibiotics.
Choice B rationale:
Administration of childhood immunizations will prevent exanthem subitum (roseola infantum) Exanthem subitum, or roseola infantum, is typically a viral illness and is not prevented by childhood immunizations. It is caused by human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7)
Choice C rationale:
Restrict fluids for children who have pertussis. Restricting fluids for children with pertussis is not recommended. Pertussis, also known as whooping cough, can cause severe coughing spells, and it is important to ensure that affected children stay well-hydrated. Restricting fluids can lead to dehydration, which can worsen the condition.
Choice D rationale:
Isolate children who have varicella until the vesicles have formed crusts. Isolation of children with varicella (chickenpox) until the vesicles have formed crusts is a standard infection control measure. Varicella is highly contagious, and isolating affected individuals helps prevent the spread of the virus to others. Once the vesicles have crusted over, the risk of transmission is significantly reduced.
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