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. .

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Correct Answer is B

Explanation

Choice A rationale

Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.

Choice B rationale

Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.

Choice C rationale

Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.

Choice D rationale

Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .

A. Helps determine if there has been bleeding to brain tissue. B. Checks for adequate oxygen intake by cerebral tissue. C. Will assess brain waves to see if seizure activity is still occurring.

Correct Answer is C

Explanation

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

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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?

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Explanation

Correct Answer is C

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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?