A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
Diminished reflexes
Rapid respirations
Acetone breath
Headache
The Correct Answer is D
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.
B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.
C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.
D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.
Correct Answer is B
Explanation
A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.
B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.
C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.
D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.
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