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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Have the child sit with her head tilted forward and hold pressure on her nose for 10 min. Tilting the head forward helps prevent blood from flowing down the throat and causing nausea or choking. Applying pressure to the nose for 10 minutes helps to stop the bleeding.
B. Place the child in a sitting position and tilt her head back. Tilted head back can cause blood to flow down the throat and potentially cause aspiration or choking. It's not recommended in managing nosebleeds.
C. Apply ice at the opening of the nares for 5 min and then re-check for bleeding. While cold compresses can help constrict blood vessels, direct pressure and maintaining a forward head position are more effective for stopping nosebleeds.
D. Place the child in a supine position with a pillow under her head. Supine position can cause blood to flow down the throat and is not recommended in managing nosebleeds due to the risk of aspiration.

A. Test the urine for ketones. B. Withhold insulin dose if feeling nauseous. C. Notify the provider if blood glucose levels are over 350 mg/dL. D. Limit fluid intake during meal time.

Correct Answer is C

Explanation

A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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