A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

Polyuria

Deep rapid respirations

Dry, flushed skin

Tachycardia

Answer and Explanation

The Correct Answer is D

A. Polyuria (excessive urination) is not a symptom of hypoglycemia; it is more commonly associated with hyperglycemia (high blood sugar).

B. Deep rapid respirations are more characteristic of diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes that leads to high blood sugar levels and metabolic acidosis.

C. Dry, flushed skin is not a typical symptom of hypoglycemia; it might be associated with conditions like dehydration or heat exposure, but not with low blood sugar.

D. Tachycardia

Explanation: The symptoms described by the adolescent (feeling shaky, difficulty speaking, difficulty concentrating) along with a blood glucose level of 55 mg/dL indicate hypoglycemia, which is low blood sugar. Tachycardia, or a rapid heart rate, is a common physiological response to hypoglycemia. The body increases the heart rate in an attempt to improve blood flow and deliver glucose to the brain and other vital organs. This is part of the body's fight-or-flight response to low blood sugar.

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Correct Answer is A

Explanation

A. You do not need to lose consciousness to suffer a concussion.

This statement is true. Concussion is a type of traumatic brain injury (TBI) that can occur without loss of consciousness. Many concussions happen without the person losing consciousness at all.

B. You will suffer permanent brain damage.

This statement is not necessarily true. While some concussions can lead to lasting effects, not all cases result in permanent brain damage. The severity and long-term effects of a concussion can vary widely.

C. We encourage fluids after a concussion.

This statement is true. Adequate hydration is important after a concussion. Staying hydrated can help support the brain's recovery process.

D. Bleeding always occurs with a concussion.

This statement is not true. Concussion is defined by the disruption of normal brain function due to a blow or jolt to the head or body, and bleeding is not always a necessary component of a concussion. However, more severe head injuries could involve bleeding and would not be classified as just a concussion.

A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position. B. Maintain an active stimulating environment C. Perform active chest percussion and suctioning every 1 to 2 hours. D. Instruct child on preforming active range of motion

Correct Answer is A

Explanation

A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.

Correct Explanation: This intervention is appropriate for a child with an acute head injury.

Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.

B. Maintain an active stimulating environment.

Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.

Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.

C. Perform active chest percussion and suctioning every 1 to 2 hours.

Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.

Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.

D. Instruct child on performing active range of motion.

Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.

Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.

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Correct Answer is A

Explanation

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