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
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.
Correct Answer is D
Explanation
Choice A rationale
Assessing the oral cavity for Koplik spots is not relevant for varicella. Koplik spots are associated with measles, not varicella. Varicella, also known as chickenpox, typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.
Choice B rationale
Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye’s syndrome. Reye’s syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella. It can cause swelling in the liver and brain.
Choice C rationale
Providing the child with a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is not a specific intervention for managing varicella. The primary focus should be on preventing the spread of the infection through appropriate precautions.
Choice D rationale
Initiating airborne precautions is essential for preventing the spread of varicella. Varicella is transmitted via airborne droplets, and using airborne precautions (such as negative air-flow rooms) helps prevent the spread of the virus to other patients and healthcare workers. If negative air-flow rooms are not available, isolating patients in closed rooms with no contact with people without evidence of immunity is recommended.