Which sign is the nurse most likely to assess in a child with hypoglycaemia?
Normal sensorium and serum glucose greater than 160 mg/dL
Urine positive for ketones and serum glucose greater than 300 mg/dL
Irritability and serum glucose less than 60 mg/dL
Increased urination and serum glucose less than 120 mg/dL
The Correct Answer is C
Hypoglycaemia is characterized by low blood sugar levels. In children, symptoms of hypoglycaemia can vary, but irritability is a common sign. Other signs and symptoms of hypoglycaemia in children may include sweating, trembling, pale skin, hunger, weakness, confusion, and dizziness.
Normal sensorium and serum glucose greater than 160 mg/dL in (Option A) is incorrect because a normal sensorium (normal level of consciousness) and a serum glucose level greater than 160 mg/dL would not be indicative of hypoglycaemia.
Urine positive for ketones and serum glucose greater than 300 mg/dL in (Option B) is incorrect because it describes characteristics of hyperglycaemia (high blood sugar levels) rather than hypoglycaemia. Positive urine ketones and a serum glucose level greater than 300 mg/dL are commonly seen in diabetic ketoacidosis, a complication of high blood sugar levels in diabetes.
Increased urination and serum glucose less than 120 mg/dL in (Option D) is incorrect because it describes increased urination and a serum glucose level less than 120 mg/dL. While a serum glucose level less than 120 mg/dL could indicate hypoglycaemia, increased urination is not a typical sign of hypoglycaemia. Increased urination may be seen in conditions such as diabetes mellitus when blood sugar levels are consistently high.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In this scenario, the child's increased urination after a serious motor vehicle crash may
indicate a potential issue with fluid balance. Monitoring the child's intake and output is the
priority action for the nurse. This involves accurately measuring and recording the fluids the
child consumes (intake) and the fluids the child eliminates through urine, sweat, and other
sources (output). By closely monitoring the child's intake and output, the nurse can assess the
child's fluid status and identify any abnormalities or imbalances that may require further
intervention.
Restrict dietary sodium intake in (option A) is incorrect because restricting dietary sodium
intake, may be necessary in certain situations, such as if the child has a known sodium
imbalance or hypertension. However, it is not the priority action in this scenario.
Assess the daily serum sodium level in (option B) is incorrect because assessing the daily
serum sodium level, is important to evaluate the child's electrolyte balance. However, it is not
the priority action compared to monitoring the child's intake and output.
Weigh the child daily in (option C) is incorrect because weighing the child daily, is a useful
measure to assess changes in fluid balance. However, it is not the priority action in this
scenario compared to monitoring the child's intake and output, which provides real-time
information on fluid balance.
Correct Answer is D
Explanation
When the skin surface is caked with desquamated skin and sebaceous secretions after the removal of a cast, the nurse should suggest washing the area with warm water and soap. This will help to gently cleanse the skin and remove the accumulated material without causing unnecessary trauma or irritation.
Option A, applying powder to absorb the material, may not effectively remove the caked material and could potentially lead to further clumping or discomfort.
Option B, vigorously scrubbing the leg, can be harsh on the skin and may cause skin irritation, redness, or even abrasions. It is important to be gentle and avoid excessive scrubbing, especially on the fragile and recently exposed skin.
Option C, carefully picking the material off the leg, can increase the risk of skin injury or introduce bacteria into the skin. Picking at the skin should be avoided to prevent further damage or infection.
Therefore, option D, washing the area with warm water and soap, is the most appropriate and gentle method to remove the caked material from the skin surface
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.