The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?

Review prior insulin prescriptions.

Obtain point-of-care glucose.

Assess urine for ketones.

Check blood pressure.

Answer and Explanation

The Correct Answer is B

The adolescent's symptoms suggest that their blood glucose levels may be very high. Obtaining a point-of- care glucose reading is the first step in assessing the adolescent's current blood glucose levels and determining the appropriate course of action.

Reviewing prior insulin prescriptions, assessing urine for ketones, and checking blood pressure are also important interventions but should occur after the blood glucose level has been determined.

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Correct Answer is B

Explanation

Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.

A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.

C. Hirschsprung's disease is a congenital condition that aﬀects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.

D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.

A. Breast milk provides adequate calories for the child. B. Regular syringe feedings promote rapid weight gain. C. High-calorie formula encourages increased growth. D. Fruit juice increases the child's daily vitamin intake.

Correct Answer is C

Explanation

The nurse should recognize that the statement "high-calorie formula encourages increased growth" is an appropriate understanding of interventions for an infant with FTT. High-calorie formula can help infants who are not gaining weight adequately to increase their calorie intake and promote growth.

Breast milk provides adequate nutrition for most infants, but in cases of FTT, the infant may require a higher calorie intake than breast milk can provide. Regular syringe feedings and fruit juice are not recommended interventions for FTT. Syringe feedings can cause aspiration and fruit juice does not provide the appropriate balance of nutrients needed for an infant's growth and development.

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The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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