A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
Diminished reflexes
Rapid respirations
Acetone breath
Headache
The Correct Answer is D
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply Neosporin to avoid infection:
This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.
B. Apply elbow immobilizers when not being held:
This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.
C. Suction secretions away from the suture line:
This is the recommended choice. Suctioning helps maintain a clear airway and prevents secretions from affecting the surgical site. It's a crucial step in the immediate postoperative period.
D. Feed increased amounts of formula to prevent weight loss:
While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.
Correct Answer is A
Explanation
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.
B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.
C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.
D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.
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