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
Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority. Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss.
Choice B rationale
Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss. This action helps to stop the bleeding and stabilize the patient.
Choice C rationale
Obtaining vital signs is important, but it can wait momentarily until the bleeding is under control. The immediate priority is to stop the bleeding.
Choice D rationale
Monitoring the pulse distal to the insertion site is important, but controlling bleeding takes precedence. Once the bleeding is controlled, the nurse can then monitor the pulse
Correct Answer is A
Explanation
Choice A rationale
Weighing the child once per day is crucial in the acute stage of nephrotic syndrome to monitor fluid retention and the effectiveness of treatment. Daily weight monitoring helps in assessing the child’s fluid balance and detecting any sudden weight gain, which could indicate worsening edema.
Choice B rationale
Increasing fluid intake to 2 L/day is not recommended for a child in the acute stage of nephrotic syndrome. This condition is characterized by significant protein loss leading to edema, and increasing fluid intake would exacerbate the problem. Fluid restriction is often necessary to manage edema.
Choice C rationale
Positioning the child supine at bedtime is not beneficial for managing nephrotic syndrome. Elevating the child’s head and legs can help reduce edema, while supine positioning might worsen it by allowing fluid to accumulate in dependent areas.
Choice D rationale
Limiting calorie intake to 45 cal/kg/day is not appropriate for a child with nephrotic syndrome. Adequate nutrition is essential for healing and recovery, and restricting calories could be harmful. The focus should be on providing a balanced diet to support the child’s overall health.