The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.

What action should the nurse take first?

Obtain point-of-care glucose.

Assess urine for ketones.

Check blood pressure.

Review prior insulin prescriptions.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The first action the nurse should take when caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision is to obtain point-of-care glucose. These symptoms are indicative of hyperglycemia, and immediate blood glucose testing is necessary to confirm this and guide further treatment.
Choice B rationale
Assessing urine for ketones is important in managing diabetes, especially in cases of suspected diabetic ketoacidosis. However, this would not be the first action to take in this scenario.
Choice C rationale
Checking blood pressure is a standard part of any physical assessment, but it would not be the first action to take in this scenario.
Choice D rationale
Reviewing prior insulin prescriptions can provide valuable information about the patient’s management of their diabetes, but it would not be the first action to take in this scenario.

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Correct Answer is D

Explanation

Choice D rationale
The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inflammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child’s symptoms.
Choice A rationale
Applying lotion to hands and feet may help with the symptom of skin peeling, but it does not address the underlying issue of the child’s irritability or refusal to eat.
Choice B rationale
While it’s important for parents to rest when possible, this does not directly address the child’s symptoms.
Choice C rationale
Making a list of foods that the child likes could potentially help with the child’s refusal to eat, but it does not address the child’s irritability or skin peeling.

A. Divide the gluteal area into quarters and give IM into the upper outer quadrant. B. Administer the injection into the middle of the lateral aspect of the thigh. C. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage. D. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.

Correct Answer is B

Explanation

Choice A rationale
Dividing the gluteal area into quarters and giving the IM injection into the upper outer quadrant is not the recommended technique for a 16-month-old toddler. This site is not typically used until after the child has begun walking regularly and has developed sufficient muscle mass.
Choice B rationale
Administering the injection into the middle of the lateral aspect of the thigh is the recommended technique for a 16-month-old toddler. The vastus lateralis muscle in the thigh is usually the preferred site for IM injections in infants and young children.
Choice C rationale
Using a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage is not the recommended technique for a 16-month-old toddler. The needle length should be appropriate for the age and size of the child, and a 1/2 inch needle may not be long enough to reach the muscle tissue.
Choice D rationale
Giving the injection in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process, is not the recommended technique for a 16-month-old toddler. The deltoid muscle in the arm is typically not used for IM injections until after the child is 3 years old.

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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.

What action should the nurse take first?