A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?
"Limit fluid intake during meal time."
"Notify the provider if blood glucose levels are over 350 milligrams/decilitre
Test the urine for ketones.
"Withhold insulin dose if feeling nauseous"
The Correct Answer is C
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistent Blood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms like frequent urination, thirst, blurry vision, or fatigue) are concerning. The client should have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
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Related Questions
Correct Answer is C
Explanation
A. Place a pillow under the child's head.
Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.
B. Clear the area of hazards.
Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.
C. Position the child side-lying.
Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions.
D. Loosen restrictive clothing.
Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.
Correct Answer is B
Explanation
A) Document intake and output:
Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.
B) Administer antibiotics when available.
Explanation:
Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.
C) Reduce environmental stimuli:
Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.
D) Maintain seizure precaution:
While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.
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