Which of the following findings should the nurse include in today's teaching? Select All That Apply.
Negative ketones.
Abdominal pain.
Double vision.
Headache.
Nightmares.
Sweating.
Excessive thirst.
Fruity breath odor.
Correct Answer : B,C,D,E,F,G
Choice A rationale
Negative ketones in the urine indicate that the body is not breaking down fat for energy. This is a normal finding and would not be considered a manifestation of a metabolic imbalance. Positive ketones, however, would be a sign of diabetic ketoacidosis (DKA), indicating that the body is in a state of ketosis due to insulin deficiency.
Choice B rationale
Abdominal pain is a significant symptom of diabetic ketoacidosis (DKA), a serious complication of hyperglycemia. The abdominal pain is thought to be caused by the metabolic acidosis, electrolyte imbalances, and gastric stasis that occur during DKA, and it can mimic other acute abdominal conditions.
Choice C rationale
Double vision, also known as diplopia, can be a symptom of severe hyperglycemia. High blood glucose levels can affect the nerves controlling the eye muscles, leading to temporary visual changes. This is a neuro-ophthalmic manifestation of a severe metabolic derangement, particularly in the context of diabetic ketoacidosis (DKA).
Choice D rationale
Headache is a common symptom of both hypoglycemia and hyperglycemia. In hyperglycemia, it is thought to be caused by dehydration and electrolyte imbalances, which can affect cerebral blood flow and pressure. It is a nonspecific but important indicator of a significant deviation from normal glucose homeostasis.
Choice E rationale
Nightmares can be a manifestation of nocturnal hypoglycemia. Low blood glucose levels during sleep can trigger a stress response, leading to disturbing dreams, restless sleep, or even waking up confused. The brain, which relies on glucose for energy, becomes dysfunctional during hypoglycemia, manifesting as vivid dreams.
Choice F rationale
Sweating is a classic and early sign of hypoglycemia. The body's physiological response to low blood glucose is to activate the sympathetic nervous system, releasing epinephrine. Epinephrine stimulates sweat glands, increases heart rate, and causes a feeling of shakiness, all in an attempt to raise blood glucose levels.
Choice G rationale
Excessive thirst, also known as polydipsia, is a cardinal sign of hyperglycemia. High glucose levels in the blood lead to osmotic diuresis, where the kidneys excrete excess glucose and water. The resulting dehydration triggers the thirst center in the brain, prompting the individual to drink more fluids to compensate.
Choice H rationale
A fruity breath odor is a pathognomonic sign of diabetic ketoacidosis (DKA). This odor is caused by the presence of ketones, specifically acetone, which is a byproduct of fat metabolism in the absence of sufficient insulin. The acetone is volatile and is exhaled through the lungs, resulting in the characteristic fruity smell.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Stating that the parent "should give the treatment a chance to work" is dismissive of their concerns and feelings. This response is judgmental and paternalistic, invalidating the parent's autonomy and their right to make healthcare decisions for their child. The nurse's role is to support and educate, not to pressure or shame the parent.
Choice B rationale
Telling the parent to discuss their concerns with the provider is a valid option but is not the best initial response. This approach defers the conversation and does not address the parent's immediate emotional state or their reasons for the decision. The nurse's first step should be to explore the parent's feelings and understanding.
Choice C rationale
Asking the parent about their reasons for the decision is the most therapeutic and patient-centered response. This open-ended question encourages the parent to express their feelings, fears, and rationale.
It demonstrates respect for their autonomy and opens a channel for a non-judgmental discussion, allowing the nurse to provide targeted support and education.
Choice D rationale
Offering to assist with gathering belongings is premature and non-therapeutic. This response assumes the parent has made a final, irreversible decision and immediately facilitates their departure without exploring the underlying reasons. It closes the door to further dialogue and does not fulfill the nurse's role as a patient advocate.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
The pneumococcal vaccine prevents infections caused by Streptococcus pneumoniae, not Streptococcus pyogenes, which is the causative agent of GABHS pharyngitis. The vaccine is not indicated for GABHS pharyngitis and would not prevent future occurrences of this specific infection. The pneumococcal vaccine is typically administered to children in a specific age-based schedule to protect against pneumonia, meningitis, and bacteremia.
Choice B rationale
Group A beta-hemolytic streptococcus is a highly contagious bacterium transmitted through respiratory droplets and direct contact. Providing the child with a separate towel helps to prevent the spread of the bacteria to other family members by avoiding fomite transmission. Fomites, such as towels, can harbor the bacteria, and sharing them increases the risk of spreading the infection. This is a critical hygiene measure.
Choice C rationale
The child's toothbrush can harbor Streptococcus pyogenes even after antibiotic therapy has begun, potentially leading to reinfection. The bristles of the toothbrush can serve as a reservoir for the bacteria, and using the same toothbrush could reintroduce the microorganisms back into the oral cavity. Replacing the toothbrush after 24 hours of antibiotics ensures the infectious source is eliminated.
Choice D rationale
A child with GABHS pharyngitis is no longer contagious after completing 24 hours of antibiotic therapy. The antibiotics effectively kill the bacteria, reducing the bacterial load to a level where it is no longer transmissible to others. This duration ensures the child is no longer a public health risk, allowing them to safely return to a school setting.
Choice E rationale
Replacing orthodontic appliances is not a standard practice for treating GABHS pharyngitis. The appliances themselves are not a significant source of bacterial reinfection and do not need to be replaced. Proper hygiene, such as cleaning the appliances, is sufficient to prevent the spread of the bacteria, making this instruction unnecessary and incorrect.
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