The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 1100, the child suddenly complains of weakness, headache, and blurred vision. How would the nurse respond?
Give the child 1⁄2 cup of orange juice to drink.
Call the dietary department and ask that the lunch tray be delivered early.
Contact the physician.
Obtain a blood glucose reading
The Correct Answer is A
A. Give the child 1⁄2 cup of orange juice to drink. These symptoms indicate hypoglycemia, a common early complication of diabetes treatment. Orange juice contains quick-acting sugars that can rapidly raise blood glucose levels and alleviate symptoms. This is the immediate action to manage the child's symptoms.
B. Call the dietary department and ask that the lunch tray be delivered early. Delayed action compared to treating the immediate hypoglycemia.
C. Contact the physician. While eventually necessary, immediate treatment of hypoglycemia takes precedence.
D. Obtain a blood glucose reading. Important to confirm hypoglycemia but not as urgent as providing immediate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I expect the color of my urine to be amber." Ferrous sulfate does not typically affect the color of urine. This statement indicates a misunderstanding of the medication's effects.
B. "I will expect dark, tarry stools." Ferrous sulfate can cause stools to become dark or black, which is a common and expected side effect due to the iron content. This indicates the client understands a normal side effect of the medication.
C. "I will not get as many infections." Ferrous sulfate is used to treat iron deficiency anemia and does not directly influence the incidence of infections. This indicates a lack of understanding of the medication’s purpose.
D. "I will take extra care to protect against increased bruising." Increased bruising is not associated with ferrous sulfate. This indicates a misunderstanding of the medication's side effects.
Correct Answer is A
Explanation
A. Projectile vomiting after feedings: Projectile vomiting after feedings, especially occurring a short time after feeding, is a classic sign of pyloric stenosis due to obstruction at the pylorus.
B. Absent bowel sounds: Absent bowel sounds may occur in more advanced cases of bowel obstruction but are not specific to pyloric stenosis.
C. Increased sodium level: Increased sodium level is not typically associated with pyloric stenosis.
D. Golf ball-size mass over the left quadrant: A palpable mass in the left quadrant is not a typical finding in pyloric stenosis.
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