Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?
A. Pallor
Pallor:Pallor refers to paleness of the skin. While it can be associated with various medical conditions, it is not a typical symptom of hyperglycemia. Pallor is more commonly seen in conditions related to anemia or circulatory issues.
B. Lethargy
Lethargy Explanation: A blood glucose level of 280 mg/dL in a school-age child indicates hyperglycemia, which is an abnormally high level of glucose in the blood. Hyperglycemia commonly occurs in diabetes mellitus, specifically in Type 1 or Type 2 diabetes. Lethargy is a symptom associated with high blood glucose levels. It is characterized by a state of extreme tiredness, sluggishness, and reduced responsiveness. Hyperglycemia can lead to an inadequate supply of glucose to the brain cells, which can result in lethargy and confusion.
C. Shallow respirations
Shallow respirations:Shallow respirations typically do not directly correlate with high blood glucose levels. Hyperglycemia's primary symptoms are related to changes in metabolism and glucose utilization, and it doesn't usually affect respiratory patterns in the same way that, for instance, respiratory distress might occur with conditions like ketoacidosis in diabetes.
D. Tremors
Tremors: Tremors, or uncontrollable shaking or trembling, are more commonly associated with hypoglycemia (low blood glucose levels) rather than hyperglycemia. Low blood glucose levels can cause the body to release adrenaline, leading to symptoms like tremors, anxiety, and sweating.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PAEDIATRICS PROCTORED EXAM - SIMMONS U BSN. Take the full exam now
Full Explanation
A. Pallor:
Pallor refers to paleness of the skin. While it can be associated with various medical conditions, it is not a typical symptom of hyperglycemia. Pallor is more commonly seen in conditions related to anemia or circulatory issues.
B. Lethargy
Explanation:
A blood glucose level of 280 mg/dL in a school-age child indicates hyperglycemia, which is an abnormally high level of glucose in the blood. Hyperglycemia commonly occurs in diabetes mellitus, specifically in Type 1 or Type 2 diabetes. Lethargy is a symptom associated with high blood glucose levels. It is characterized by a state of extreme tiredness, sluggishness, and reduced responsiveness. Hyperglycemia can lead to an inadequate supply of glucose to the brain cells, which can result in lethargy and confusion.
C. Shallow respirations:
Shallow respirations typically do not directly correlate with high blood glucose levels. Hyperglycemia's primary symptoms are related to changes in metabolism and glucose utilization, and it doesn't usually affect respiratory patterns in the same way that, for instance, respiratory distress might occur with conditions like ketoacidosis in diabetes.
D. Tremors:
Tremors, or uncontrollable shaking or trembling, are more commonly associated with hypoglycemia (low blood glucose levels) rather than hyperglycemia. Low blood glucose levels can cause the body to release adrenaline, leading to symptoms like tremors, anxiety, and sweating.
Similar Questions
A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?
A. Can always track an object with eyes
Can always track an object with eyes:The ability to track an object with the eyes typically develops in infants around 2 to 3 months of age. This developmental milestone is not specific to cerebral palsy and is generally expected in healthy infants.
B. Needs support with pillow props for sitting
Needs support with pillow props for sitting Explanation: Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. It is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. The symptoms of cerebral palsy can vary widely, but they are generally related to motor function and coordination. The manifestation of needing support with pillow props for sitting is consistent with the motor impairments often seen in cerebral palsy. Children with cerebral palsy may have difficulties with muscle control and coordination, which can affect their ability to sit independently. The need for external support to maintain a sitting position is indicative of motor developmental delays or challenges associated with cerebral palsy.
C. Uses a pincer grasp to pick up a toy
Uses a pincer grasp to pick up a toy: The pincer grasp, where a child uses the thumb and index finger to pick up small objects, usually develops around 9 to 12 months of age. This developmental milestone is not directly associated with cerebral palsy and is part of normal infant development.
D. Smiles when a parent appears
Smiles when a parent appears:Smiling in response to familiar faces, including parents, is a social and emotional developmental milestone that typically occurs around 2 to 3 months of age. While cerebral palsy can affect motor function, it does not directly impact an infant's ability to express emotions like smiling.
Full Explanation
A. Can always track an object with eyes:
The ability to track an object with the eyes typically develops in infants around 2 to 3 months of age. This developmental milestone is not specific to cerebral palsy and is generally expected in healthy infants.
B. Needs support with pillow props for sitting
Explanation:
Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. It is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. The symptoms of cerebral palsy can vary widely, but they are generally related to motor function and coordination.
The manifestation of needing support with pillow props for sitting is consistent with the motor impairments often seen in cerebral palsy. Children with cerebral palsy may have difficulties with muscle control and coordination, which can affect their ability to sit independently. The need for external support to maintain a sitting position is indicative of motor developmental delays or challenges associated with cerebral palsy.
C. Uses a pincer grasp to pick up a toy:
The pincer grasp, where a child uses the thumb and index finger to pick up small objects, usually develops around 9 to 12 months of age. This developmental milestone is not directly associated with cerebral palsy and is part of normal infant development.
D. Smiles when a parent appears:
Smiling in response to familiar faces, including parents, is a social and emotional developmental milestone that typically occurs around 2 to 3 months of age. While cerebral palsy can affect motor function, it does not directly impact an infant's ability to express emotions like smiling.
Evidence has demonstrated that we can do a great deaI to prevent and minimalize the occurence of CTE (Concussion Tramatic Encephalophy), damage due to repetitive head injuries. Which of the answers below are true:
A. You do not need to lose consciousness to suffer a concussion,
You do not need to lose consciousness to suffer a concussion.This statement is true. Concussion is a type of traumatic brain injury (TBI) that can occur without loss of consciousness. Many concussions happen without the person losing consciousness at all.
B. You will suffer permanent brain damage
You will suffer permanent brain damage.This statement is not necessarily true. While some concussions can lead to lasting effects, not all cases result in permanent brain damage. The severity and long-term effects of a concussion can vary widely.
C. We encourage fluids after a concussion
We encourage fluids after a concussion.This statement is true. Adequate hydration is important after a concussion. Staying hydrated can help support the brain's recovery process.
D. Bleeding always occurs with a concussion
Bleeding always occurs with a concussion.This statement is not true. Concussion is defined by the disruption of normal brain function due to a blow or jolt to the head or body, and bleeding is not always a necessary component of a concussion. However, more severe head injuries could involve bleeding and would not be classified as just a concussion.
Full Explanation
A. You do not need to lose consciousness to suffer a concussion.
This statement is true. Concussion is a type of traumatic brain injury (TBI) that can occur without loss of consciousness. Many concussions happen without the person losing consciousness at all.
B. You will suffer permanent brain damage.
This statement is not necessarily true. While some concussions can lead to lasting effects, not all cases result in permanent brain damage. The severity and long-term effects of a concussion can vary widely.
C. We encourage fluids after a concussion.
This statement is true. Adequate hydration is important after a concussion. Staying hydrated can help support the brain's recovery process.
D. Bleeding always occurs with a concussion.
This statement is not true. Concussion is defined by the disruption of normal brain function due to a blow or jolt to the head or body, and bleeding is not always a necessary component of a concussion. However, more severe head injuries could involve bleeding and would not be classified as just a concussion.
Why do we instruct care givers about preventing kidney injury in their baby or child under 2 years old?
A. Kidneys are very small and irregular
Kidneys are very small and irregular.Explanation: This statement is not the primary reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. While it is true that infant and toddler kidneys are relatively smaller and have a slightly different shape compared to adult kidneys, the main concern for kidney injury prevention in this age group is related to other factors.
B. The occurence of Hirsutism.
The occurrence of Hirsutism.Explanation: Hirsutism refers to excessive hair growth, typically in a male pattern, in women and children. It is not directly related to kidney injury prevention in babies or children under 2 years old. Hirsutism is usually caused by hormonal imbalances and is not a primary consideration when instructing caregivers about preventing kidney injury.
C. Diaper rashes
Diaper rashes. Explanation: Diaper rashes are skin irritations that occur in the diaper area of infants and young children. While diaper rashes can be uncomfortable and require proper care, they are not a major concern when instructing caregivers about preventing kidney injury. Diaper rashes are typically a result of prolonged exposure to moisture and can be managed with good hygiene practices and appropriate diaper-changing routines.
D. Children under two years old are more vulnerable to kidney trauma from compression force to abdomen.
Children under two years old are more vulnerable to kidney trauma from compression force to abdomen.Explanation: This statement is true and is the main reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. Children in this age group have relatively larger abdomens and less developed abdominal muscles, which makes their kidneys more susceptible to injury from compression forces to the abdomen. This is why caregivers are advised to handle young children carefully, avoid rough play, and ensure that they are securely fastened in car seats and other safety devices to prevent potential kidney trauma.
Full Explanation
A) Kidneys are very small and irregular.
Explanation: This statement is not the primary reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. While it is true that infant and toddler kidneys are relatively smaller and have a slightly different shape compared to adult kidneys, the main concern for kidney injury prevention in this age group is related to other factors.
B) The occurrence of Hirsutism.
Explanation: Hirsutism refers to excessive hair growth, typically in a male pattern, in women and children. It is not directly related to kidney injury prevention in babies or children under 2 years old. Hirsutism is usually caused by hormonal imbalances and is not a primary consideration when instructing caregivers about preventing kidney injury.
C) Diaper rashes.
Explanation: Diaper rashes are skin irritations that occur in the diaper area of infants and young children. While diaper rashes can be uncomfortable and require proper care, they are not a major concern when instructing caregivers about preventing kidney injury. Diaper rashes are typically a result of prolonged exposure to moisture and can be managed with good hygiene practices and appropriate diaper-changing routines.
D) Children under two years old are more vulnerable to kidney trauma from compression force to abdomen.
Explanation: This statement is true and is the main reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. Children in this age group have relatively larger abdomens and less developed abdominal muscles, which makes their kidneys more susceptible to injury from compression forces to the abdomen. This is why caregivers are advised to handle young children carefully, avoid rough play, and ensure that they are securely fastened in car seats and other safety devices to prevent potential kidney trauma.