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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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. .
Correct Answer is A
Explanation
Choice A rationale
Automatisms, such as eye blinking and lip smacking, are repetitive, involuntary movements commonly associated with absence seizures. They occur due to brief interruptions in consciousness during seizure activity without major motor involvement.
Choice B rationale
Neurotoxin exposure typically presents with symptoms like weakness, ataxia, and autonomic dysfunction. Increased eye blinking and lip smacking are not specific to neurotoxin-related neurological damage or poisoning.
Choice C rationale
Hyponatremia causes confusion, lethargy, and muscle cramps due to electrolyte disturbance affecting cellular function, but it does not cause specific automatisms like eye blinking or lip smacking in seizure-related conditions.
Choice D rationale
Reversible adverse effects of anticonvulsants often include sedation or cognitive slowing. Automatisms such as blinking and smacking are not typically linked to the pharmacological effects of anticonvulsants.
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