A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
“I will continue to check his blood sugar two times every day.”
"I will report a change in her breathing or any signs of confusion.”
“I will encourage her to drink half a cup of water or sugar-free fluid every 30 minutes”
"I will notify the doctor if her temperature is not controlled by acetaminophen”
The Correct Answer is A
A. "I will continue to check his blood sugar two times every day."
Correct Explanation: This statement indicates a need for further instruction.
Explanation: A child with type 1 diabetes requires frequent blood sugar monitoring, especially during illness. Checking blood sugar only twice a day is not sufficient, especially when the child has an upper respiratory infection. Illness can impact blood sugar levels, so more frequent monitoring is necessary to ensure proper diabetes management.
B. "I will report a change in her breathing or any signs of confusion."
Incorrect Explanation: This statement shows awareness of potential complications and the need to monitor for them.
Explanation: Children with type 1 diabetes are at risk of diabetic ketoacidosis (DKA) when they are sick. Changes in breathing patterns and signs of confusion are symptoms of DKA. Reporting these symptoms is important, as it could indicate a serious diabetic complication.
C. "I will encourage her to drink half a cup of water or sugar-free fluid every 30 minutes."
Incorrect Explanation: This statement demonstrates proper fluid management, especially during illness.
Explanation: Encouraging the child to stay hydrated with sugar-free fluids is essential, particularly when the child has an upper respiratory infection. Proper hydration helps prevent dehydration, which can be more concerning for a child with diabetes.
D. "I will notify the doctor if her temperature is not controlled by acetaminophen."
Incorrect Explanation: This statement shows an understanding of the importance of managing fever in a child with diabetes.
Explanation: Children with diabetes can experience difficulty managing blood sugar levels when they're sick. Fever can exacerbate this issue. Using acetaminophen to control fever is appropriate, and notifying the doctor if fever persists is a responsible action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Always infantize the child
Incorrect Explanation: "Infantizing" a child with a growth hormone deficiency is not a relevant or appropriate approach.
Explanation: Growth hormone deficiency is a medical condition that affects a child's growth. Treating the child as an infant could potentially have negative psychological and social effects. It's important to provide appropriate support and understanding without treating the child differently due to their medical condition.
B. Monitor for leukemia
Incorrect Explanation: Monitoring for leukemia is not directly related to growth hormone deficiency.
Explanation: Growth hormone deficiency primarily affects a child's growth and development due to inadequate production of growth hormone. While there might be certain health concerns associated with the condition, monitoring for leukemia is not a common aspect of managing growth hormone deficiency.
C. Help the parents set realistic goals based on the child's age and abilities
Correct Explanation: This is an important aspect to include in teaching.
Explanation: When a child is diagnosed with growth hormone deficiency, it's crucial for parents to set realistic expectations regarding their child's growth. Growth hormone therapy can help, but it's essential to understand that the child's growth might still differ from their peers. Setting realistic goals based on the child's age and abilities can help manage expectations and provide appropriate support.
D. This illness is only seen in males
Incorrect Explanation: Growth hormone deficiency is not limited to males.
Explanation: Growth hormone deficiency can affect individuals of any gender. It is not exclusive to males. The condition results from insufficient production of growth hormone by the pituitary gland, and it can occur in both males and females.
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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