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

Answer and Explanation

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.

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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

A. Elevating the head but give nothing by mouth B. Elevating the head for feedings C. Avoiding suction unless infant is cyanotic D. Feeding glucose water only

Correct Answer is A

Explanation

When caring for a neonate with a suspected tracheoesophageal fistula (TEF), nursing care should include elevating the head but giving nothing by mouth. Tracheoesophageal fistula is a condition where an abnormal connection exists between the trachea and oesophagus, leading to the passage of air and secretions between these structures. Feeding the infant orally can result in aspiration of feedings into the lungs, which can cause respiratory distress and complications. Therefore, it is important to keep the neonate in an upright position to reduce the risk of aspiration until a definitive diagnosis and treatment plan are established.

elevating the head for feedings in (option B), is not appropriate in this case as oral feedings should be avoided until the tracheoesophageal fistula is addressed.

avoiding suction unless the infant is cyanotic in (option C), is not correct. Suctioning may be necessary in neonates with suspected tracheoesophageal fistula to clear secretions and maintain a patent airway.

feeding glucose water only in (option D), is not an appropriate intervention for a neonate with a suspected tracheoesophageal fistula. In this situation, all oral feedings should be withheld until further evaluation and management.

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Which sign is the nurse most likely to assess in a child with hypoglycaemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?

Correct Answer is D

Explanation

The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care should include which of the following?

Correct Answer is A

Explanation

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