A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

Pallor

Lethargy

Shallow respirations

Tremors

Answer and Explanation

The Correct Answer is B

A. Pallor:

Pallor refers to paleness of the skin. While it can be associated with various medical conditions, it is not a typical symptom of hyperglycemia. Pallor is more commonly seen in conditions related to anemia or circulatory issues.

B. Lethargy

Explanation:

A blood glucose level of 280 mg/dL in a school-age child indicates hyperglycemia, which is an abnormally high level of glucose in the blood. Hyperglycemia commonly occurs in diabetes mellitus, specifically in Type 1 or Type 2 diabetes. Lethargy is a symptom associated with high blood glucose levels. It is characterized by a state of extreme tiredness, sluggishness, and reduced responsiveness. Hyperglycemia can lead to an inadequate supply of glucose to the brain cells, which can result in lethargy and confusion.

C. Shallow respirations:

Shallow respirations typically do not directly correlate with high blood glucose levels. Hyperglycemia's primary symptoms are related to changes in metabolism and glucose utilization, and it doesn't usually affect respiratory patterns in the same way that, for instance, respiratory distress might occur with conditions like ketoacidosis in diabetes.

D. Tremors:

Tremors, or uncontrollable shaking or trembling, are more commonly associated with hypoglycemia (low blood glucose levels) rather than hyperglycemia. Low blood glucose levels can cause the body to release adrenaline, leading to symptoms like tremors, anxiety, and sweating.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Assume you made a mistake and report out the same head circumference as before.

Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.

Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.

B. Take Vital Signs.

Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.

Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.

C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.

Correct Explanation: This is the best next step.

Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.

D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.

Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.

A. Dizziness is always a sign of a concussion B. Bike helmet safety C. Normal fluid intake D. Signs of autism

Correct Answer is B

Explanation

A. Dizziness is always a sign of a concussion.

This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.

B. Bike Helmet Safety

Explanation:

The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.

C. Normal fluid intake.

While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.

D. Signs of autism.

Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.

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A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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