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A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the Questions the nurse is asking. The nurse checks the adolescent’s blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

A.

Polyuria.

B.

Dry, flushed skin.

C.

Deep, rapid respirations.

D.

Tachycardia.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Polyuria, or excessive urination, is typically associated with hyperglycemia rather than hypoglycemia. In the context of diabetes, polyuria occurs when high blood glucose levels lead to increased urine production as the body attempts to excrete excess glucose. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, polyuria is not an expected finding.

 

Choice B rationale

 

Dry, flushed skin is a common symptom of hyperglycemia, not hypoglycemia. When blood glucose levels are high, the body becomes dehydrated, leading to dry skin and a flushed appearance. In contrast, hypoglycemia often presents with symptoms such as sweating, pallor, and shakiness due to the body’s response to low blood glucose levels.

 

Choice C rationale

 

Deep, rapid respirations, also known as Kussmaul respirations, are typically associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia. DKA occurs when the body produces high levels of ketones due to insufficient insulin. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, deep, rapid respirations are not an expected finding.

 

Choice D rationale

 

Tachycardia, or an increased heart rate, is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases catecholamines (such as adrenaline) to raise blood glucose levels. This response leads to symptoms such as shakiness, sweating, and tachycardia. Therefore, tachycardia is an expected finding in an adolescent with a blood glucose level of 55 mg/dL.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Slightly yellow sclera, or jaundice, is a common finding in children with sickle cell anemia. The breakdown of sickled red blood cells leads to increased bilirubin levels in the blood, which can cause jaundice. This yellowing is often most noticeable in the sclera of the eyes. Jaundice is a result of hemolysis, a hallmark of sickle cell anemia, where red blood cells are destroyed faster than they can be produced.

Choice B rationale

Depigmented areas on the abdomen are not typically associated with sickle cell anemia. Sickle cell anemia primarily affects the blood and organs, leading to complications such as pain crises, anemia, and organ damage. Skin changes like depigmentation are not characteristic of this condition and may indicate other underlying issues.

Choice C rationale

Enlarged mandibular growth is not a common finding in sickle cell anemia. While children with sickle cell anemia may experience growth delays and skeletal abnormalities due to chronic anemia and bone marrow hyperactivity, mandibular enlargement is not a typical feature. Skeletal changes in sickle cell anemia are more likely to involve long bones and vertebrae.

Choice D rationale

Increased growth of long bones is not a characteristic finding in sickle cell anemia. In fact, children with sickle cell anemia may experience growth delays and shorter stature due to chronic anemia and the body’s increased demand for red blood cell production. The condition can lead to skeletal abnormalities, but these typically involve bone infarctions and deformities rather than increased growth.

Correct Answer is D

Explanation

Choice A rationale

At 10 months, infants are typically able to imitate simple sounds, including animal sounds. This is a normal developmental milestone.

Choice B rationale

Turning pages in a book is a fine motor skill that develops later, around 12 months of age.

Choice C rationale

Building a tower of three or four cubes is a skill that typically develops around 15-18 months of age.

Choice D rationale

By 10 months, infants should be able to sit steadily without support. Inability to do so may indicate a developmental delay.

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