A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

"Sweating can occur with hypoglycemia."

"My son might complain of feeling shaky when he has a low blood glucose level."

"My son might have nausea and vomiting with hypoglycemia."

"The onset of low blood glucose usually occurs rapidly."

Answer and Explanation

The Correct Answer is C

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.

D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.

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Correct Answer is D

Explanation

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

A. "I will allow the position my mother finds most comfortable during the feeding." B. "I will turn my mother on her left side during the feeding." C. "I will position the head of the bed 45 degrees during the feeding." D. "I will elevate the head of the bed 10 degrees during the feeding."

Correct Answer is C

Explanation

A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.

D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

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A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

Correct Answer is C

Explanation

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