The nurse is caring for a 10-year-old who has an acute head injury, has a pediatric Glasgow coma score of 9. and is unconscious. Which interventions should the nurse include in the child's care plan?

A. Pallor:

Pallor refers to paleness of the skin. While it can be associated with various medical conditions, it is not a typical symptom of hyperglycemia. Pallor is more commonly seen in conditions related to anemia or circulatory issues.

B. Lethargy

Explanation:

A blood glucose level of 280 mg/dL in a school-age child indicates hyperglycemia, which is an abnormally high level of glucose in the blood. Hyperglycemia commonly occurs in diabetes mellitus, specifically in Type 1 or Type 2 diabetes. Lethargy is a symptom associated with high blood glucose levels. It is characterized by a state of extreme tiredness, sluggishness, and reduced responsiveness. Hyperglycemia can lead to an inadequate supply of glucose to the brain cells, which can result in lethargy and confusion.

C. Shallow respirations:

Shallow respirations typically do not directly correlate with high blood glucose levels. Hyperglycemia's primary symptoms are related to changes in metabolism and glucose utilization, and it doesn't usually affect respiratory patterns in the same way that, for instance, respiratory distress might occur with conditions like ketoacidosis in diabetes.

D. Tremors:

Tremors, or uncontrollable shaking or trembling, are more commonly associated with hypoglycemia (low blood glucose levels) rather than hyperglycemia. Low blood glucose levels can cause the body to release adrenaline, leading to symptoms like tremors, anxiety, and sweating.

A) Low-protein, low-potassium diet:

While low-protein and low-potassium diets can be appropriate for certain kidney conditions, such as chronic kidney disease, they are not typically the primary focus in the acute phase of glomerulonephritis. Protein restriction might be considered if there is significant kidney damage, and potassium levels are elevated.

B) Low-sodium fluid-restricted diet:

This is the most appropriate option. In acute glomerulonephritis, the kidneys' ability to regulate sodium and fluid balance may be impaired due to inflammation and decreased glomerular filtration. Fluid retention and peripheral edema are common. A low-sodium diet helps reduce fluid retention and manage edema.

C) Low carbohydrate, low-protein diet:

Low-carbohydrate and low-protein diets are not the main dietary considerations for acute glomerulonephritis. The primary focus is on managing sodium and fluid intake due to impaired kidney function.

D) Regular diet, no added salt:

A regular diet without added salt might exacerbate the fluid retention and edema associated with acute glomerulonephritis. Sodium intake needs to be controlled to prevent further fluid buildup.