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.
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Related Questions
Correct Answer is D
Explanation
A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
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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