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
A change in status that should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury is confusion and altered mental status. As intracranial pressure increases, it can affect brain function and lead to neurological changes, including confusion, disorientation, irritability, decreased level of consciousness, or other alterations in mental status. These changes indicate that the brain is being compressed and compromised, and immediate intervention is required.
Option B, increased diastolic pressure with narrowing pulse pressure in (option B) is incorrect because it, can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or systemic conditions. It is important to consider the overall hemodynamic status of the child and assess for additional signs and symptoms of increased ICP.
irregular, rapid heart rate in (option C), can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or other medical conditions. Assessment of heart rate should be considered along with other signs and symptoms of increased ICP.
rapid, shallow breathing, in (option D) can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or respiratory conditions. Respiratory assessment should be considered along with other signs and symptoms of increased ICP.
Correct Answer is B
Explanation
The primary concern when it comes to a synthetic cast is to keep it dry during bathing or showering. Moisture can weaken the cast material and lead to skin irritation or infection. Therefore, covering the cast with plastic and waterproof tape helps to protect it from getting wet.
Applying a heating pad to the cast if the child has swelling in the affected extremity in (Option A) is incorrect because applying a heating pad to the cast can increase the risk of burns and is not recommended. If the child has swelling in the affected extremity, it is important to elevate the limb and follow any specific instructions provided by the healthcare provider.
Splitting the cast if the child complains of numbness or pain in (Option C) is also incorrect. Splitting the cast, or attempting to modify or adjust it, should not be done without medical supervision. If the child complains of numbness or pain, it is important to notify the healthcare provider for further evaluation and appropriate management.
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Wrapping the outer surface of the cast with an Ace bandage in (Option D) is incorrect as well. Wrapping the outer surface of the cast with an Ace bandage or any additional material is not recommended unless specifically instructed by the healthcare provider. It can affect the fit of the cast, alter the healing process, and potentially cause complications |
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