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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 D

Explanation


Choice A rationale

Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. It is not commonly associated with tetralogy of Fallot.

Choice B rationale

Polycythemia, or an increased number of red blood cells, can occur as a compensatory mechanism in response to chronic hypoxia in tetralogy of Fallot. However, it is not a primary condition associated with tetralogy of Fallot.

Choice C rationale

Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries. While it can occur secondary to congenital heart defects, it is not a primary condition associated with tetralogy of Fallot.

Choice D rationale

Tetralogy of Fallot is a congenital heart defect that includes four heart abnormalities: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. These defects cause altered blood flow and reduced oxygen levels in the blood.

Correct Answer is A

Explanation

Choice A rationale

High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.

Choice B rationale

Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.

Choice C rationale

Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.

Choice D rationale


Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.

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