A nurse is assessing a 7-year-old child who has diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
Increased capillary refill
Shakiness
Thirst
Decreased appetite
The Correct Answer is B
The correct answer is B. Shakiness.
Choice A: Increased capillary refill Capillary refill time (CRT) is a simple and quick test requiring minimal equipment or time to perform. Prolonged CRT is a ‘red flag’ feature, identifying children with increased risk of significant morbidity or mortality. A normal CRT should be between 2-3 seconds when applied centrally, such as to the sternum or the forehead. Therefore, increased capillary refill is not typically associated with hypoglycemia.
Choice B: Shakiness Shakiness, or tremors, are rhythmic shaking movements that most often happen in the hands, but can also occur in the arms, legs, head, vocal cords, and torso. Tremors can occur while a child is resting or active. Shakiness is a common symptom of hypoglycemia.
Choice C: Thirst While it’s true that excessive thirst can be a sign of diabetes, it’s a tricky one when the patient is a child. Young children often drink plenty of fluids when they are perfectly healthy. However, thirst is typically associated with hyperglycemia, not hypoglycemia.
Choice D: Decreased appetite Loss of appetite (anorexia) is a common symptom in children. Acute illness in childhood is often associated with transient loss of appetite. However, decreased appetite is not typically a direct symptom of hypoglycemia.
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Correct Answer is B
Explanation
Communicate with the healthcare team.
To ensure comprehensive care during the treatment and management of dehydration in children, communication with the healthcare team is essential.
Here's the rationale for this choice:
Choice A rationale:
Administer electrolyte solutions only.
This is not The correct approach.
While administering electrolyte solutions is a vital part of managing dehydration, it is not the only aspect of care.
Comprehensive care also includes assessing the child's overall condition, monitoring vital signs, and addressing any underlying causes of dehydration.
Choice B rationale:
Communicate with the healthcare team.
This is The correct answer.
Dehydration management often requires a multidisciplinary approach.
Communicating with the healthcare team, which may include physicians, dietitians, and other specialists, is crucial to ensure that the child receives appropriate treatment and that any underlying medical issues are addressed.
It also allows for coordinated care and adjustment of the treatment plan as needed.
Choice C rationale:
Rely solely on clinical signs to assess hydration status.
Relying solely on clinical signs is not sufficient for comprehensive care.
While clinical signs are important indicators of hydration status, laboratory tests and monitoring are also necessary to accurately assess and manage dehydration.
Choice D rationale:
Skip monitoring the child's response to treatment.
Skipping monitoring is not advisable.
Monitoring the child's response to treatment is a critical part of dehydration management.
It helps ensure that the child is improving, and adjustments can be made to the treatment plan if necessary.
Correct Answer is A
Explanation
Choice A rationale:
Albumin (5% or 25%) Albumin is the most appropriate IV fluid for a client with hypoalbuminemia and shock.
Albumin is a colloid solution that helps to increase oncotic pressure, which can be decreased in conditions like hypoalbuminemia.
This increased oncotic pressure can help draw fluids back into the vascular space, improving intravascular volume and blood pressure.
Therefore, it is a suitable choice for a patient with shock.
The two concentrations mentioned, 5% and 25%, refer to the percentage of albumin in the solution, and the choice between them depends on the severity of the patient's condition and the desired effect.
The 5% solution is often used for volume expansion and to improve hemodynamics, while the 25% solution is used for rapid volume expansion.
Choice B rationale:
Dextrans (Dextran-40 or Dextran-70) Dextrans are another type of colloid solution, but they are not the best choice for this specific situation.
Dextrans are often used as volume expanders but are more commonly employed in conditions where there is no issue with albumin levels.
In this case, the primary concern is hypoalbuminemia, and using albumin-based solutions would be more appropriate.
Choice C rationale:
Gelatin (Gelofusine or Haemaccel) Gelatin-based solutions are also colloids and can be used for volume expansion.
However, they are not the best choice for a patient with hypoalbuminemia because they do not address the low albumin levels.
Albumin solutions are preferred in such cases to help restore oncotic pressure and improve intravascular volume.
Choice D rationale:
Plasma protein fraction (Plasmanate or Plasmasteril) Plasma protein fraction solutions, also known as human albumin, are similar to albumin solutions.
However, in this context, albumin solutions are more commonly used.
Plasma protein fraction solutions may be indicated in specific situations, but the primary choice for a patient with hypoalbuminemia and shock would be albumin-based solutions, as they are specifically designed to address albumin deficiencies.
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