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 D
Explanation
Choice A rationale
Placing the infant in a recumbent position during feeding is not recommended as it can increase the risk of aspiration. The infant should be held in an upright or semi-upright position to facilitate safe swallowing and digestion.
Choice B rationale
Allowing the infant 45 minutes for each feeding can be too long and may lead to fatigue and decreased feeding efficiency. It is generally recommended to limit feeding sessions to 20-30 minutes to ensure the infant gets adequate nutrition without becoming overly tired.
Choice C rationale
Allowing the infant to self-soothe by crying prior to feeding is not advisable, especially for infants with heart failure. Crying can increase the infant’s metabolic demands and oxygen consumption, which can be detrimental to their condition.
Choice D rationale
Implementing a 3-hour feeding schedule helps ensure that the infant receives regular and consistent nutrition. This schedule can help manage the infant’s energy levels and prevent fatigue, which is important for infants with heart failure.
Correct Answer is C
Explanation
Choice A rationale
A hemoglobin level of 6.8 g/dL is significantly lower than the normal range (9.5 to 14 g/dL) and indicates anemia. This finding does not suggest that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice B rationale
An RBC count of 5/mm³ is within the normal range (4 to 5.5/mm³) but does not specifically indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice C rationale
A WBC count of 15,000/mm³ is higher than the normal range (5,000 to 10,000/mm³) but can indicate that the treatment is having a therapeutic effect. In the context of acute lymphoblastic leukemia, an elevated WBC count can be a sign that the body is responding to treatment.
Choice D rationale
A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³) and does not indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.