A nurse is caring for an 11-year-old child who has type 1 diabetes mellitus and receives insulin injections. The child is experiencing an altered mental status, diaphoresis, and tremors. Which of the following actions should the nurse take?
Give the child 3 to 6 oz of orange juice.
Give the child a candy bar.
Administer glucagon to the vastus lateralis.
Administer DSW intravenous fluids.
The Correct Answer is A
A. Give the child 3 to 6 oz of orange juice. The child's altered mental status, diaphoresis, and tremors indicate hypoglycemia. The best initial treatment for mild to moderate hypoglycemia is a fast-acting carbohydrate, such as orange juice (3 to 6 oz) to rapidly raise blood glucose levels.
B. Give the child a candy bar. While candy contains sugar, it also contains fat, which slows glucose absorption, delaying the correction of hypoglycemia.
C. Administer glucagon to the vastus lateralis. Glucagon is used for severe hypoglycemia (e.g., unconsciousness or seizures), not for mild to moderate symptoms.
D. Administer D5W intravenous fluids. IV dextrose is used in severe cases where the child is unconscious or unable to take oral glucose. Since this child is conscious, oral treatment is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"B"}}
Explanation
Bacterial Meningitis (Most Likely Diagnosis). Headache, nausea, irritability, lethargy, nuchal rigidity → Signs of meningeal irritation Petechiae → Possible meningococcal sepsis. Fever, chills, elevated WBC count (14,000/mm³) → Indicates an infection. Irregular respirations, agitation, capillary refill 4 seconds → Signs of worsening perfusion, possible sepsis
Hodgkin Lymphoma (Possible but Less Likely). Enlarged lymph nodes → Common in lymphoma but does not explain acute symptoms like fever, petechiae, or neurologic signs.
Acute Lymphoblastic Leukemia (ALL) (Possible but Less Likely). Petechiae → Possible due to thrombocytopenia, but child’s platelet count (350,000) is normal.. Enlarged lymph nodes → Can occur in leukemia but is not the primary concern given the acute symptoms.
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