A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
"I will report changes in breathing or signs of confusion."
"I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."
"I will notify the doctor if his temperature is not controlled with acetaminophen."
"I will continue to check his blood sugar two times every day."
The Correct Answer is D
A. "I will report changes in breathing or signs of confusion." Correct action as changes in breathing or confusion can indicate diabetic ketoacidosis or other serious complications.
B. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."Ensuring adequate fluid intake helps prevent dehydration and helps manage blood sugar levels during illness.
C. "I will notify the doctor if his temperature is not controlled with acetaminophen." Correct action as fever may indicate an infection that needs further medical evaluation and treatment.
D. "I will continue to check his blood sugar two times every day." When a child with diabetes is ill, blood sugar should be monitored more frequently, typically every 3-4 hours, to manage the risk of hyperglycemia or hypoglycemia due to illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rigid abdomen: A rigid abdomen is not typically associated with Hirschsprung disease unless there is severe obstruction and distension.
B. Ribbonlike, foul-smelling stools: Hirschsprung disease causes obstruction of the colon, leading to constipation and ribbonlike, foul-smelling stools proximal to the affected segment.
C. Projectile vomiting: Projectile vomiting is not typically associated with Hirschsprung disease but may occur in other conditions causing bowel obstruction.
D. Chronic hunger: Chronic hunger is not a typical finding in Hirschsprung disease and is more indicative of metabolic or endocrine disorders.
Correct Answer is D
Explanation
A. "I'm tired and want to take a nap." Common in sick children and not necessarily concerning in this context.
B. "I am scared and I want to go home." Emotional response, typical in children facing surgery.
C. "I am hungry and thirsty." Normal sensations and not indicative of the severity of the condition.
D. "My belly doesn't hurt anymore." This statement suggests potential rupture or perforation of the appendix, which can lead to peritonitis and is a surgical emergency. A sudden relief of pain can indicate a worsening condition rather than improvement.
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