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?
Polyuria.
Dry, flushed skin.
Deep, rapid respirations.
Tachycardia.
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
Auscultating the rate and characteristics of the child’s heart sounds is the priority assessment. Acute rheumatic fever can lead to carditis, which affects the heart valves and can cause new or changed heart murmurs.
Choice B rationale
Assessing the client’s erythematous rash is important but not the priority. The rash is a common symptom but does not indicate the severity of the condition.
Choice C rationale
Identifying the degree of parental anxiety is important for providing holistic care but is not the immediate priority in assessing the child’s physical condition.
Choice D rationale
Using a pain-rating tool to determine the severity of joint pain is important for managing symptoms but is not the priority assessment upon admission.
Correct Answer is B
Explanation
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.