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 B
Explanation
Choice A rationale
Performing the dressing change independently does not demonstrate effective collaboration. Effective collaboration involves working with other healthcare professionals to provide the best care for the patient. By performing the dressing change independently, the nurse is not utilizing the expertise and support of the healthcare team.
Choice B rationale
Seeking guidance from the wound care nurse demonstrates effective collaboration. The wound care nurse has specialized knowledge and skills in wound management, and seeking their guidance ensures that the patient receives the best possible care. This collaborative approach enhances patient outcomes and promotes a team-based approach to healthcare.
Choice C rationale
Asking another nurse to complete the dressing change does not demonstrate effective collaboration. While delegating tasks can be part of collaboration, it is important that the nurse seeks guidance from the appropriate specialist, in this case, the wound care nurse, to ensure the best care for the patient.
Choice D rationale
Consulting only the client’s family for assistance does not demonstrate effective collaboration. While involving the family in the care process is important, it is essential to collaborate with other healthcare professionals who have the expertise to provide the best care for the patient.
Correct Answer is B
Explanation
Choice A rationale
Serous chest tube drainage is a normal finding and does not typically indicate a complication. It is usually clear or pale yellow fluid that is expected after surgery.
Choice B rationale
Chest tube drainage of 200 mL in 1 hour is excessive and should be reported to the provider. This could indicate active bleeding or other complications that require immediate attention.
Choice C rationale
Fluctuation in the water-sealed chamber, also known as tidaling, is a normal finding and indicates that the chest tube is functioning properly. It reflects changes in pressure within the pleural space during respiration.
Choice D rationale
A respiratory rate of 22/min is within the normal range for a school-age child and does not typically indicate a complication.