A nurse is caring for an adolescent client who has type 1 diabetes mellitus. The adolescent reports mild symptoms and a serum glucose level of 55 g/dL. Which of the following should the nurse give the client?

1 tsp of peanut butter

Glass of orange juice

Glucagon injection

1 tsp of sugar

Answer and Explanation

The Correct Answer is B

Hypoglycemia in clients with type 1 diabetes mellitus occurs when blood glucose levels fall below normal, often due to excess insulin, missed meals, or increased physical activity. Mild hypoglycemia (typically 50–70 mg/dL) is managed with rapid-acting oral carbohydrates to quickly raise blood glucose levels. Prompt treatment is essential to prevent progression to severe hypoglycemia, which can lead to confusion, seizures, or loss of consciousness. Interventions depend on the client’s level of consciousness and ability to swallow safely.

Rationale:
A. Peanut butter contains fat and protein, which slow gastric emptying and delay glucose absorption. Although it may help stabilize blood sugar later, it is not appropriate for rapid correction of acute hypoglycemia. Fast-acting carbohydrates are required first to quickly restore serum glucose levels.

B. A glass of orange juice provides fast-acting simple carbohydrates that are rapidly absorbed in the gastrointestinal tract. This leads to a quick increase in blood glucose levels, making it appropriate for mild hypoglycemia when the client is conscious and able to swallow. It is a standard first-line intervention for immediate glucose correction.

C. Glucagon is indicated for severe hypoglycemia when the client is unconscious or unable to safely swallow. It works by stimulating hepatic glycogen breakdown to raise blood glucose levels. Since the client is alert with mild symptoms, glucagon is not the first-line treatment in this situation.

D. Sugar alone in small amounts such as 1 teaspoon may provide some glucose, but it is not as effective or reliable as liquid glucose sources. Liquids are absorbed more rapidly than solid or granulated sugar. Therefore, oral glucose solutions like juice or glucose tablets are preferred for faster correction of hypoglycemia.

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Correct Answer is A

Explanation

A 12-lead electrocardiogram (ECG) is a noninvasive diagnostic test used to assess the heart’s electrical activity and identify dysrhythmias, ischemia, and other cardiac abnormalities. Accurate interpretation depends on proper electrode placement and minimizing artifacts caused by movement or muscle activity. Patient preparation is essential to ensure clear waveform recordings and reliable results. Nursing care focuses on positioning, comfort, and instruction to reduce interference during the procedure.

Rationale:
A. Instructing the client to remain as still as possible during the recording is essential to obtain an accurate ECG tracing. Movement, talking, or muscle tension can create artifacts that distort the electrical signals and make interpretation difficult. Stillness ensures that the recorded cardiac activity reflects true electrical conduction of the heart.

B. Telling the client to expect a mild stinging sensation during the test is incorrect because a 12-lead ECG is a completely noninvasive and painless procedure. The electrodes only detect electrical activity and do not deliver any electrical current to the body. Clients may feel adhesive from the electrode pads but should not experience pain or discomfort.

C. Assisting the client to the orthopneic position is not appropriate for obtaining a standard 12-lead ECG. The preferred position is supine or semi-Fowler’s to ensure accurate electrode placement and consistent recordings. Orthopneic positioning is typically used to improve breathing in clients with respiratory distress, not for ECG acquisition.

D. Attaching a blood pressure cuff to the client’s upper arm is not required for a standard 12-lead ECG. ECG monitoring focuses on electrical activity through skin electrodes placed on the chest and limbs. A blood pressure cuff may be used for vital sign monitoring but is not part of the ECG setup procedure.

A. Well-groomed appearance B. Flight of ideas C. Command hallucinations D. Ritualistic behavior

Correct Answer is B

Explanation

Bipolar disorder involves alternating periods of depression and mania or hypomania. During manic episodes, clients often exhibit elevated mood, increased energy, decreased need for sleep, and rapid, pressured speech. Cognitive processes become accelerated, leading to disorganized and rapid shifts in thought. Nursing assessment focuses on identifying behavioral and cognitive changes associated with manic or depressive phases.

Rationale:
A. Well-groomed appearance is not typically expected in clients experiencing mania. During manic episodes, clients often present with disheveled appearance due to distractibility, increased activity, and decreased attention to self-care. Although grooming may vary, it is not a defining feature of bipolar disorder.

B. Flight of ideas is a hallmark symptom of the manic phase of bipolar disorder. It involves rapid, continuous shifting from one idea to another that is often loosely connected. This reflects increased thought speed and distractibility commonly seen in manic episodes.

C. Command hallucinations are more commonly associated with psychotic disorders such as schizophrenia rather than bipolar disorder. Although psychotic features may occur in severe mania, hallucinations are not a primary expected finding in bipolar disorder.

D. Ritualistic behavior is more characteristic of obsessive-compulsive disorder rather than bipolar disorder. It involves repetitive, compulsive actions aimed at reducing anxiety. This behavior is not typically associated with manic or depressive episodes in bipolar disorder.

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A nurse is caring for an adolescent client who has type 1 diabetes mellitus. The adolescent reports mild symptoms and a serum glucose level of 55 g/dL. Which of the following should the nurse give the client?

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