A nurse is assessing a 7-year-old child who has diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
Increased capillary refill.
Decreased appetite.
Thirst.
Shakiness.
The Correct Answer is D
Choice A rationale
Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation but is not a common sign of low blood sugar levels.
Choice B rationale
Decreased appetite is not typically associated with hypoglycemia. Hypoglycemia usually causes symptoms such as shakiness, sweating, and confusion.
Choice C rationale
Thirst is not typically associated with hypoglycemia. It is more commonly a symptom of hyperglycemia (high blood sugar levels).
Choice D rationale
Shakiness or tremors are common signs of hypoglycemia. When blood sugar levels drop, the body responds by releasing adrenaline, which can cause shakiness.
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Correct Answer is A
Explanation
Choice A rationale
Prednisone is a corticosteroid that suppresses the immune system, making the child more susceptible to infections. Therefore, monitoring for signs of infection is crucial.
Choice B rationale
Prednisone can cause potassium loss, so limiting potassium-rich foods is not recommended. Instead, maintaining a balanced diet is important.
Choice C rationale
Prednisone does not stimulate growth spurts. In fact, long-term use can potentially stunt growth in children.
Choice D rationale
Discontinuing prednisone abruptly can cause adrenal insufficiency. If gastrointestinal upset occurs, the medication should be taken with food or the dosage adjusted, but not discontinued without consulting a healthcare provider.
Correct Answer is A
Explanation
Choice A rationale
Ensuring that all patients are moved out of harm’s way is the first priority in a nursing home fire situation. This action aligns with the principles of the ABCs of nursing prioritization, where ensuring safety and preventing harm is paramount.
Choice B rationale
Removing all flammable materials from the area and extinguishing the fire is important, but it comes after ensuring the safety of the patients. The primary focus should be on patient safety.
Choice C rationale
Reporting to the area of the fire and taking measures to extinguish and/or contain it, if possible, is a secondary action. The immediate priority is to ensure the safety of the patients.
Choice D rationale
Evacuating all patients from the building immediately is not always feasible or safe. The priority is to move patients out of immediate harm’s way and then proceed with further evacuation if necessary.