A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

Administer 40 ounces of fruit juice.

Administer 15 grams of simple carbohydrates in the form of hard candy.

Administer 50 mL of Dextrose 50% IV push.

Repeat the blood glucose test after 15 minutes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering 40 ounces of fruit juice would result in excessive carbohydrate intake and is inappropriate for treating hypoglycemia. Standard treatment includes 15 grams of carbohydrates or intravenous glucose for severe symptoms.

Choice B rationale

Hard candy provides 15 grams of carbohydrates, suitable for a patient who is alert and able to safely swallow. However, this client exhibits confusion and lethargy, necessitating a quicker, safer IV intervention.

Choice C rationale

Administering Dextrose 50% IV push rapidly raises blood glucose levels, effectively treating hypoglycemia in symptomatic, confused, or unconscious patients. This intervention bypasses the gastrointestinal tract for immediate action.

Choice D rationale

Rechecking glucose after 15 minutes is essential after treatment but does not address acute hypoglycemia. Delaying treatment risks prolonged hypoglycemia, increasing the risk of neuronal injury or further clinical deterioration. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Approaching the client from the unaffected side does not stimulate compensation or adaptation. It limits the opportunity for neural adjustment and rehabilitation to optimize functional use of the affected side.

Choice B rationale

Eye patches may address double vision but are ineffective in enhancing sensory perception compensation for hemianopsia. Rehabilitation focuses on improving spatial awareness, not restricting visual fields.

Choice C rationale

Muscle exercises aid ocular health but do not scientifically compensate for hemianopsia. Scanning techniques provide more effective sensory perception rehabilitation in spatial deficits caused by this condition.

Choice D rationale

Scanning techniques teach clients to move their head or eyes consciously to view their entire surroundings. This method compensates for sensory deficits, helping clients adapt effectively during rehabilitation. .

A. Bipolar disorder. B. Pre-existing liver disease. C. Asthma. D. Migraine headaches.

Correct Answer is B

Explanation

Choice A rationale

Bipolar disorder is an approved indication for valproic acid use. It helps stabilize mood swings, particularly mania, making it a suitable treatment rather than a contraindication.

Choice B rationale

Pre-existing liver disease contraindicates valproic acid because it increases the risk of hepatic toxicity and liver failure. Liver function must be closely monitored in all patients receiving this drug.

Choice C rationale

Asthma is not affected by valproic acid use as the drug targets neurological pathways and does not impact respiratory or bronchial systems significantly.

Choice D rationale

Valproic acid is used to treat migraines and seizures. It prevents the occurrence of severe headaches through stabilization of neuronal activity, making this an appropriate rather than contraindicated use. .

View Question and Answer

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

A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with homonymous hemianopsia resulting from a stroke has a disturbed sensory perception.An appropriate nursing intervention to help the client learn to compensate for this deficit during the rehabilitation period would be to:

Correct Answer is D

Explanation

The nurse knows that an important contraindication for valproic acid use is:

Correct Answer is B

Explanation

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior.What would be the best response by the nurse?

A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle accident.What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury.Which actions should the nurse take to achieve this goal? (Select All that Apply.)

A client's daughter asks the nurse for assistance in communicating with her mother who has sensorineural hearing loss.Which point is appropriate for the nurse to teach?

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the family of a patient diagnosed with a brain injury.The nurse states, "The ventriculostomy is placed:

A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?