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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D"}
Explanation
Pilonidal dimpling with the presence of an abnormal tuft of hair in or near the dimple
Explanation:
Spina bifida is a congenital condition where there is incomplete closing of the backbone and membranes around the spinal cord during early development in the womb. Pilonidal dimpling with the presence of an abnormal tuft of hair in or near the dimple is a specific sign of spina bifida. This condition is called "sacral dimple," and it can indicate an underlying issue with the spinal cord and nerves. An abnormal tuft of hair in or near the dimple suggests a neural tube defect, which is characteristic of spina bifida.
Why the other choices are incorrect:
A. complete paralysis:
Complete paralysis is a severe neurological symptom but it is not specific to spina bifida. It can occur due to various other conditions as well, such as spinal cord injuries, infections, and neurological disorders. It's not a characteristic sign of spina bifida.
B. Petechiae:
Petechiae are small, red or purple spots on the skin that are caused by bleeding under the skin. They are usually associated with bleeding disorders, infections, or other medical conditions. Petechiae are not a characteristic sign of spina bifida.
C. Abnormal Vital Signs:
While spina bifida can potentially lead to neurological complications that might influence vital signs, the presence of abnormal vital signs is a non-specific symptom. Abnormal vital signs could be caused by a wide range of medical conditions, and they are not directly indicative of spina bifida.
Correct Answer is D
Explanation
Reflexes play a crucial role in evaluating the neurological status of infants.
Moro reflex: Also known as the startle reflex, the Moro reflex is a normal response in infants. It occurs when an infant is startled by a sudden noise or movement. The baby responds by extending their arms and legs, followed by a quick contraction. This reflex usually disappears around 4-6 months of age.
Tonic neck reflex (fencer's reflex): This reflex involves turning an infant's head to one side, causing the arm on that side to extend and the opposite arm to flex. It's a normal reflex that typically disappears around 4-6 months of age.
Withdrawal reflex: The withdrawal reflex is a normal response to a stimulus, such as touching a baby's foot with a cold object. The baby will pull their leg away in response to the stimulus.
Symptomatic of decorticate or decerebrate posturing (options A and B):
Decorticate and decerebrate posturing are abnormal postures seen in individuals with severe brain damage or injury. Decorticate posturing involves the arms being flexed and held close to the body, while decerebrate posturing involves the arms being extended and the wrists being pronated. These reflexes are typically indicative of significant neurological dysfunction and are not expected in a 2-month-old infant after a car accident.
Indicators of severe brain damage (option C):
The reflexes described (Moro, tonic neck, and withdrawal reflexes) are not indicative of severe brain damage in a 2-month-old infant. These reflexes are normal for an infant of this age and are part of their typical neurological development.
Normal findings (option D):
The reflexes described are normal findings in a 2-month-old infant and are expected as part of their developmental milestones.
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