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 A
Explanation
The most appropriate statement by the nurse to a 15-year-old whose friend has mentioned suicide is option A. The statement acknowledges the seriousness of the situation and emphasizes the importance of taking the friend's threat seriously. It also highlights the need for immediate help and intervention. Suicide threats should never be dismissed or taken lightly, and it is crucial to involve professionals who can provide appropriate support and assistance.
"Tell your friend to come to the clinic immediately," in option B is incorrect because places the responsibility solely on the 15-year-old to relay the message to their friend, which may not be the most effective or timely approach.
"If your friend mentions suicide again, get your friend some help," in (option C) is incorrect because it does not address the urgency of the situation. Waiting for the friend to mention suicide again before acting may lead to potential harm.
"You need to gather details about your friend's suicide plan," is incorrect because places the responsibility on the 15-year-old to gather information about the friend's suicidal intentions. While understanding the situation and obtaining relevant details is important, the immediate priority is ensuring the friend's safety and seeking professional help.
Correct Answer is C
Explanation
Hydrocephalus refers to a condition characterized by an abnormal accumulation ofcerebrospinal fluid (CSF) within the ventricles of the brain. In infants, hydrocephalus cancause the head to enlarge rapidly as a result of the increased pressure exerted by theaccumulatingfluid.Thisisknownas"rapidheadgrowth."Theincreasedintracranialpressurecanlead to irritabilityand poorappetite in infants.
The distended scalp veins are another common sign of hydrocephalus. As the fluidaccumulates,itputs pressureon thebloodvessels inthe brain,causingtheveinsin thescalptobecome morevisible and distended.
Cerebral palsy in (option A) is incorrect because is a neurological disorder that affects bodymovementandmusclecoordination,butitdoesnottypicallypresentwithrapid headgrowthordistended scalp veins.
Syndrome of inappropriate antidiuretic hormone (SIADH) in (option B) is incorrect becauseitisacondition characterized byexcessivesecretionofantidiuretichormone,leadingtofluidimbalance, but it does not usually cause rapid head growth or distended scalp veins. Reye'ssyndrome (D) is a rare condition that primarily affects the liver and brain, and it does nottypicallypresent with rapid headgrowthor distended scalp veins.
Therefore, based on the signs described, hydrocephalus (C) is the most likely disorder in thiscase.Itisimportantto seekmedicalattentionpromptlyforaproperdiagnosisand appropriatemanagementofhydrocephalus in infants.
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