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.
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Correct Answer is A
Explanation
Choice A rationale
Ignoring temper tantrums is an effective strategy for managing this behavior. By not giving attention to the tantrum, the child learns that this behavior will not achieve the desired outcome. This approach helps reduce the frequency and intensity of tantrums over time.
Choice B rationale
Restraining the child physically during a temper tantrum can escalate the situation and may cause injury to the child or the caregiver. It is not recommended as a strategy for managing temper tantrums.
Choice C rationale
Distracting the child by offering to play a game can be an effective strategy for preventing tantrums, but it is not the best approach once a tantrum has already started. Ignoring the tantrum is more effective in reducing the behavior over time.
Choice D rationale
Telling the child that temper tantrums are not acceptable may not be effective during the tantrum itself. The child is unlikely to be receptive to verbal reasoning during a tantrum. Ignoring the tantrum is a more effective strategy.
Correct Answer is A
Explanation
Choice A rationale
Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and ready for administration. This step is crucial for delivering the correct dose of medication.
Choice B rationale
Pressing down twice on the MDI canister is incorrect as it can lead to an overdose of medication. The correct technique involves pressing down once per inhalation.
Choice C rationale
Waiting 2 minutes between inhalations is not necessary. The recommended wait time between inhalations is usually 30 seconds to 1 minute.
Choice D rationale
Rinsing the mouth with mouthwash after inhaling the medication is not recommended. Instead, rinsing with water is advised to prevent oral thrush, especially when using corticosteroid inhalers.