A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?
Polyuria
Deep rapid respirations
Dry, flushed skin
Tachycardia
The Correct Answer is D
A. Polyuria (excessive urination) is not a symptom of hypoglycemia; it is more commonly associated with hyperglycemia (high blood sugar).
B. Deep rapid respirations are more characteristic of diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes that leads to high blood sugar levels and metabolic acidosis.
C. Dry, flushed skin is not a typical symptom of hypoglycemia; it might be associated with conditions like dehydration or heat exposure, but not with low blood sugar.
D. Tachycardia
Explanation: The symptoms described by the adolescent (feeling shaky, difficulty speaking, difficulty concentrating) along with a blood glucose level of 55 mg/dL indicate hypoglycemia, which is low blood sugar. Tachycardia, or a rapid heart rate, is a common physiological response to hypoglycemia. The body increases the heart rate in an attempt to improve blood flow and deliver glucose to the brain and other vital organs. This is part of the body's fight-or-flight response to low blood sugar.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
Correct Answer is B
Explanation
A. Dizziness is always a sign of a concussion.
This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.
B. Bike Helmet Safety
Explanation:
The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.
C. Normal fluid intake.
While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.
D. Signs of autism.
Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.
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