A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?

Choice A: This statement indicates a lack of understanding of the teaching, as insulin should not be stored in the freezer, as freezing can damage the insulin and make it ineffective. Insulin should be stored in a cool and dry place, away from direct sunlight and heat sources. Unopened bottles of insulin can be stored in the refrigerator until their expiration date, but opened bottles of insulin can be kept at room temperature for up to 28 days.

Choice B: This statement indicates a lack of understanding of the teaching, as the morning blood glucose level for a child who has type 1 diabetes mellitus should be between 70 and 110 mg/dL, according to the American Diabetes Association. A blood glucose level between 90 and 130 mg/dL may indicate hyperglycemia, which is high blood sugar and can cause symptoms such as thirst, hunger, fatigue, or frequent urination. A blood glucose level below 70 mg/dL may indicate hypoglycemia, which is low blood sugar and can cause symptoms such as sweating, shaking, dizziness, or confusion.

Choice C: This statement indicates an understanding of the teaching, as eating a snack half an hour before playing soccer can help prevent hypoglycemia, which is low blood sugar, in a child who has type 1 diabetes mellitus. Physical activity can lower blood sugar levels by increasing the uptake of glucose by the muscles. Eating a snack that contains carbohydrates and protein can provide energy and prevent a sudden drop in blood sugar levels during or after exercise.

Choice D: This statement indicates a lack of understanding of the teaching, as regular insulin should not be skipped or stopped when a child who has type 1 diabetes mellitus is sick. In fact, insulin may need to be increased or adjusted when a child is sick, as illness can raise blood sugar levels by causing stress hormones or inflammation. The child should monitor their blood sugar levels more frequently when they are sick and follow their sick day plan that includes taking insulin, checking for ketones, staying hydrated, and contacting their provider if needed.

Choice A: This instruction is incorrect, as withholding insulin dose if feeling nauseous can cause hyperglycemia, which is high blood sugar, and diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should take their insulin dose as prescribed and monitor their blood sugar levels more frequently when they are sick.

Choice B: This instruction is unnecessary, as notifying the provider if blood glucose levels are within normal parameters does not require any action or intervention. The child and the parents should notify the provider if blood glucose levels are above or below the target range, which is usually 70 to 180 mg/dL for children with type 1 diabetes mellitus. The child and the parents should also notify the provider if they have any signs or symptoms of hypoglycemia, hyperglycemia, or diabetic ketoacidosis.

Choice C: This instruction is incorrect, as limiting fluid intake during mealtime can cause dehydration, which can worsen the symptoms and complications of type 1 diabetes mellitus. Dehydration can cause increased thirst, dry mouth, fatigue, headache, or dizziness. The child should drink plenty of fluids during meal time and throughout the day to hydrate their body and flush out excess glucose and ketones.

Choice D: This instruction is correct, as testing the urine for ketones can help detect diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should test their urine for ketones when their blood sugar levels are above 240 mg/dL or when they are sick. The child and the parents should notify the provider if the urine test shows moderate or large amounts of ketones.