A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take?

Choice A reason: Tremors are not a likely finding in a child with hyperglycemia, or high blood glucose. Tremors are more commonly associated with hypoglycemia, or low blood glucose, as the body releases adrenaline to stimulate the release of glucose from the liver. Tremors may also be caused by anxiety, caffeine, or certain medications.

Choice B reason: Shallow respirations are not a likely finding in a child with hyperglycemia, unless the child has developed diabetic ketoacidosis (DKA), a serious complication of diabetes that occurs when the body breaks down fat for energy and produces ketones, which are acidic substances that can cause metabolic acidosis. In DKA, the child may have rapid and deep breathing, also known as Kussmaul respirations, as the body tries to eliminate excess carbon dioxide and acid. However, DKA usually occurs when the blood glucose level is above 300 mg/dL, and the child may also have other signs and symptoms, such as nausea, vomiting, abdominal pain, fruity breath, and confusion.

Choice C reason: Pallor is not a likely finding in a child with hyperglycemia, as the blood flow to the skin is not affected by high blood glucose. Pallor is more commonly associated with anemia, shock, or hypoxia, which are conditions that reduce the oxygen-carrying capacity of the blood or the blood flow to the tissues.

Choice D reason: Lethargy is a likely finding in a child with hyperglycemia, as high blood glucose can cause dehydration, electrolyte imbalance, and impaired brain function. The child may feel tired, weak, and drowsy, and have difficulty concentrating or staying awake. Lethargy may also indicate that the child is at risk of developing DKA, which can lead to coma and death if not treated promptly.

Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.

Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.

Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.

Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.