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 D
Explanation
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
Correct Answer is A
Explanation
Choice A rationale
Testing the urine for ketones is essential for managing type 1 diabetes, especially during illness. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.
Choice B rationale
While notifying the provider if blood glucose levels are over 350 mg/dL is important, it is not the most immediate action required during illness management. High blood glucose levels can indicate poor diabetes control, but ketone testing is more critical during illness to prevent ketoacidosis.
Choice C rationale
Withholding insulin when feeling nauseous is incorrect. Insulin should not be withheld during illness, as blood glucose levels can increase due to stress or infection. Continuing insulin administration is crucial to prevent hyperglycemia and ketoacidosis.
Choice D rationale
Limiting fluid intake during mealtime is not recommended. Proper hydration is essential for overall health and helps manage blood glucose levels. Fluids should be consumed as needed, especially during illness.