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 C
Explanation
Choice A rationale
This is incorrect because the child’s feet should be able to touch the ground comfortably when seated on the bicycle, kbut not necessarily 3 to 6 inches off the ground. Proper seat height is crucial for balance and control.
Choice B rationale
Riding against the flow of traffic is dangerous and increases the risk of accidents. Bicyclists should always ride with the flow of traffic to be more predictable to drivers.
Choice C rationale
Walking the bicycle through intersections is a key safety measure to prevent accidents. It ensures that the child is more visible to drivers and reduces the risk of collisions.
Choice D rationale
Keeping the bicycle at least 3 feet from the curb is not a standard safety recommendation. Instead, children should ride as close to the curb as safely possible, following the flow of traffic.
Correct Answer is D
Explanation
Choice A rationale
Encouraging flexion and extension of the neck is contraindicated for a client with a halo vest as it can compromise the stability of the cervical spine.
Choice B rationale
Assessing the pin sites for infection once every other day is not sufficient. Pin sites should be assessed at least once per shift to detect and manage any potential infections early.
Choice C rationale
Tightening the screws on the halo device one-quarter turn every 48 hours is not recommended. Adjustments to the halo device should only be made by a healthcare provider to ensure the integrity of the device and the stability of the cervical spine.
Choice D rationale
Repositioning the client using a turning sheet is the correct action. This method helps to reposition the client safely without exerting unnecessary pressure on the cervical spine and aids in preventing pressure ulcers.