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
Lengthening the harness straps weekly is not recommended. The Pavlik harness is designed to maintain the hip joint in a stable position to promote proper development. Adjusting the straps without professional guidance can compromise the effectiveness of the treatment and potentially harm the infant.
Choice B rationale
Positioning the diaper over the straps with each change is correct. This ensures that the harness remains in the correct position and prevents soiling of the harness, which can lead to skin irritation and infection.
Choice C rationale
Massaging the skin under the straps daily is not advised. The harness should remain in place to maintain the correct hip position. Removing the harness for skin massage can disrupt the treatment.
Choice D rationale
Applying lotion to the skin beneath the straps twice daily is not recommended. Lotions can cause the skin to become too moist, leading to skin breakdown and irritation. The harness should remain dry to prevent skin issues.
Correct Answer is C
Explanation
Choice A rationale
The inactivated polio virus (IPV) vaccine is typically administered at 2 months, 4 months, and 6-18 months of age, not at 12 months.
Choice B rationale
The hepatitis B vaccine is given at birth, 1-2 months, and 6-18 months of age.
Choice C rationale
The varicella (chickenpox) vaccine is recommended to be given at 12-15 months of age for the first dose.
Choice D rationale
The human papillomavirus (HPV) vaccine is recommended for preteens aged 11-12 years, not for infants.