Nokea
A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom[s] indicate(s) that the hyperglycemia requires immediate intervention? Select all that apply.
- A. Weakness.
- B. Thirst.
- C. Shakiness.
- D. Hunger.
- E. Headache.
- F. Irritability.
- G. Dizziness.
Correct Answer: B,E,F
Rationale: Thirst, headache, and irritability are hallmark symptoms of hyperglycemia progressing to diabetic ketoacidosis, requiring immediate intervention. Weakness, shakiness, hunger, and dizziness suggest hypoglycemia instead.
You may also like to solve these questions
When positioning a neonate with an unrepaired myelomeningocele, which of the following positions is most appropriate?
- A. Supine with the hips at 90-degree flexion.
- B. Right side-lying position with the knees flexed.
- C. Prone with hips in abduction.
- D. Supine in semi-Fowler's position with chest and abdomen elevated.
Correct Answer: C
Rationale: The prone position protects the myelomeningocele sac from pressure and rupture before surgical repair, with hips in abduction to maintain alignment and prevent strain on the defect.
A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend?
- A. Home schooling.
- B. Restriction from participating in athletic activities.
- C. Avoiding trips to the shopping mall.
- D. Being treated as 'normal' as much as possible.
Correct Answer: D
Rationale: Normal activities promote psychological well-being in leukemia, with precautions for infection and bleeding risks.
A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother develop a plan of care to stimulate the child's appetite. Which of the following suggestions made by the mother would indicate that she needs additional teaching?
- A. Deciding that she will feed the child herself.
- B. Withholding dessert and treats unless meals are eaten.
- C. Offering the child finger foods that the child likes.
- D. Serving smaller and more frequent meals.
Correct Answer: B
Rationale: Withholding desserts can create negative associations with eating, reducing appetite. Feeding assistance, finger foods, and smaller meals are appropriate to encourage intake in a burn patient with high metabolic needs.
The nurse is assessing a child with celiac disease. Which symptom should the nurse expect?
- A. Constipation.
- B. Abdominal distension.
- C. Fever.
- D. Joint pain.
Correct Answer: B
Rationale: Abdominal distension is a common symptom of celiac disease due to malabsorption and gas. Diarrhea is more typical than constipation, and fever or joint pain are less specific.
The nurse has identified a priority nursing diagnosis of Anxiety related to surgery for a 4-yearold preparing for a tonsillectomy. The nurse should tell the child:
- A. You won't have so many sore throats after your tonsils are removed.
- B. The doctor will put you to sleep so you don't feel anything.
- C. Show me how to give the doll an I.V.
- D. When it is done you will get to see your mommy and get a Popsicle.
Correct Answer: D
Rationale: When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduce anxiety, avoid the word 'removed' to describe what is being done to the tonsils. Using the terms 'put to sleep' and 'I.V.' may be threatening. Additionally, directing a play experience to focus on I.V. insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.