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
Having their cell phone visible and diverting the eyes to check messages is not an effective nonverbal technique for enhancing the importance of education. It can be distracting and may convey a lack of interest or attention to the client.
Choice B rationale
Crossing arms over the chest and avoiding eye contact can be perceived as defensive or disinterested body language. It does not enhance the importance of education and may create a barrier to effective communication.
Choice C rationale
Smiling, nodding, and touching the client’s hand are positive nonverbal techniques that can enhance the importance of education. These actions convey warmth, empathy, and attentiveness, making the client feel valued and understood.
Choice D rationale
Leaning gently over the back of a chair with legs crossed can be perceived as casual or relaxed body language. It does not convey the importance of the education being provided.
Correct Answer is B
Explanation
Choice A rationale
Assisting the adolescent to ambulate 12 hours following surgery is not recommended. Early ambulation is important, but 12 hours post-surgery is too soon and can lead to complications such as increased pain and risk of injury.
Choice B rationale
Ensuring two nurses logroll the adolescent every 2 hours is crucial. Logrolling helps maintain spinal alignment and prevents complications such as pressure ulcers and respiratory issues.
Choice C rationale
Maintaining the head of the bed at a 30° angle is not appropriate immediately post-surgery as it can increase pressure on the surgical site and compromise spinal alignment.
Choice D rationale
Offering sips of water 4 hours following surgery is not recommended. Postoperative patients are usually kept NPO (nothing by mouth) for a certain period to prevent aspiration and other complications.