PEDS: Metabolic

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids. Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

A nurse is caring for a hospitalized child who has hypotonic dehydration. Which serum sodium level would this student expect to observe? 1. 125 mEq/L (125 mmol/L) 2. 135 mEq/L (135 mmol/L) 3. 145 mEq/L (145 mmol/L) 4. 155 mEq/L (155 mmol/L)

1. 125 mEq/L (125 mmol/L) Rationale: Hypotonic dehydration occurs when the loss of electrolytes is greater than the loss of water; in this type of dehydration, the serum sodium level is less than 130 mEq/L (130 mmol/L). Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal at 135 to 145 mEq/L (135 to 145 mmol/L).

An adolescent with diabetes receives 30 units of Humulin N insulin at 7:00 a.m. The nurse would monitor for a hypoglycemic episode at what time? 1. At bedtime 2. Before supper 3. At midmorning 4. After breakfast

2. Before supper Rationale: Humulin N insulin is an intermediate-acting insulin that peaks in approximately 6 to 12 hours. It would peak before supper if given at 7:00 a.m. Short-acting insulin would peak after breakfast or midmorning. Long-acting insulins would peak at bedtime.

A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. Which statement should the nurse educator include in the session? 1. "Treatment includes dietary restriction of tyramine." 2. "Phenylketonuria is an autosomal dominant disorder." 3. "Phenylketonuria primarily affects the gastrointestinal system." 4. "All 50 states require routine screening of all newborn infants for phenylketonuria."

4. "All 50 states require routine screening of all newborn infants for phenylketonuria." Rationale: All 50 states require routine screening in newborn infants. Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood.

The nurse is teaching the parent of a preschool child how to administer the child's insulin injection. The child will be receiving 2 units of Humulin R insulin and 12 units of Humulin N insulin every morning. How should the nurse instruct the parents to prepare the insulin? 1. Draw the insulin into separate syringes. 2. Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. 3. Draw the Humulin N insulin first and then the Humulin R insulin into the same syringe. 4. Check blood glucose first, and if the result is between 70 and 110 mg/dL (4 and 6 mmol/L), withhold the insulin injection.

2. Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. Rationale: When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the long-acting insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the Humulin R insulin would be drawn into the syringe first, followed by the Humulin N insulin. When a child's insulin dosage requires the injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single injection. Blood glucose results between 70 and 110 mg/dL (4 and 6 mmol/L) are considered to be euglycemic (normal), and the prescribed dose would be administered to maintain euglycemia.

The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. Which statement by the parents indicates an understanding of preventing and managing hyperglycemia? 1. "I will give 8 oz of diet cola at the first sign of weakness." 2. "I will administer glucagon immediately if shakiness is felt." 3. "I will check for ketones when my child is suffering from an illness." 4. "I will report to the emergency department if the blood glucose level is over 150 mg/dL (8.6 mmol/L)."

3. "I will check for ketones when my child is suffering from an illness." Rationale: It is recommended that urine be tested for ketones every 3 hours during an illness or whenever the blood glucose level is over 240 mg/dL (13.7 mmol/L) when illness is not present. The child or parents should carry a source of glucose so it is readily available in the event of a hypoglycemic, not hyperglycemic, reaction. A diet carbonated beverage does not meet the need of providing a glucose source during a hypoglycemic episode. If the blood glucose level is greater than 150 mg/dL (8.6 mmol/L), it is unnecessary to report to the emergency department as a first-line treatment. Glucagon is used for an unconscious client who is experiencing a hypoglycemic, not hyperglycemic, reaction and who is unable to swallow.

The nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous potassium for the treatment of dehydration. Which assessment finding requires the need to notify the health care provider? 1. Weight increase of 0.5 kg 2. Temperature of 100.8°F (38.2°C) rectally 3. A decrease in urine output to 0.5 mL/kg/hr 4. Blood pressure unchanged from baseline

3. A decrease in urine output to 0.5 mL/kg/hr Rationale: The priority assessment is to assess the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A blood pressure that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.035. 3. Capillary refill is less than 2 seconds. 4. Urine output is less than 1 mL/kg/hour.

3. Capillary refill is less than 2 seconds. Rationale: Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.035, and no tears would indicate that the deficit is not resolving.

The nurse provides instructions to the adolescent regarding the administration of insulin. The nurse should include which instruction? 1. Rotate each insulin injection site on a weekly basis. 2. Alternate between the thighs and hips for injections. 3. Check the blood glucose before administering insulin. 4. Avoid using the arms for injections because it is too difficult of a procedure to perform.

3. Check the blood glucose before administering insulin. Rationale: The nurse should teach the adolescent to check the blood glucose before administering insulin. This is important for the adolescent to know to help maintain euglycemia. To help decrease variations in absorption, the child should use different locations within a major inject site for one day. The next day, another major site may be used, depending on the site rotation schedule. The parent should give two or three injections a week in areas that are difficult for the child to reach but it is not necessary to avoid the arms and the adolescent can be taught how to self-administer in the arm.

An adolescent with type 1 diabetes mellitus has been chosen for the school's cheerleading squad. The adolescent visits the school nurse to obtain information regarding adjustments needed in the treatment plan for diabetes. What should the school nurse instruct the student to do? 1. Eat half the amount of food normally eaten. 2. Take two times the amount of prescribed insulin on practice and game days. 3. Eat six graham crackers or drink a cup of orange juice prior to practice or game time. 4. Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning.

3. Eat six graham crackers or drink a cup of orange juice prior to practice or game time. Rationale: An extra snack of 15 to 30 g of carbohydrate eaten before activities, such as cheerleader practice, will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased.

An adolescent with type 1 diabetes mellitus is attending a dance in the school gym. The adolescent suddenly becomes flushed and complains of hunger and dizziness. The school nurse, who is present at the dance, takes the child to the nurse's office and performs a blood glucose level test that shows 60 mg/dL (3.4 mmol/L). Which is the initial nursing intervention? 1. Call the child's mother. 2. Assist the child with administering regular insulin. 3. Give the child ½ cup (120 ml) of a sugar-sweetened carbonated beverage. 4. Call an ambulance to take the child to the hospital emergency department.

3. Give the child ½ cup (120 ml) of a sugar-sweetened carbonated beverage. Rationale: A blood glucose level lower than 70 mg/dL (4 mmol/L) indicates hypoglycemia. The child is attending an activity that is different from the normal routine at school. Insulin requirements change with unfamiliar situations. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Regular insulin will lower the blood glucose level and is thus a harmful action. Although the child's mother will need to be notified of the occurrence, this is not the immediate action. There is no reason to take the child to the emergency department.

A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia? 1. Daily glucose monitor log 2. Dietary history for the previous week 3. Glycosylated hemoglobin (hemoglobin A1c) 4. Fasting blood glucose performed on the day of the clinic visit

3. Glycosylated hemoglobin (hemoglobin A1c) Rationale: The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time limited in its scope, as is the dietary history.

An adolescent is examined in the hospital emergency department after taking an overdose of acetylsalicylic acid. The adolescent has rapid breathing, nausea and vomiting, and lethargy. The health care provider prescribes arterial blood specimens for blood gas analysis to be drawn. Aspirin toxicity is suspected when the blood gas results are reported as which value? 1. pH 7.50, Pco2 60 mmHg, HCO3 30 mEq/L (30 mmol/L) 2. pH 7.44, Pco2 30 mmHg, HCO3 21 mEq/L (21 mmol/L) 3. pH 7.29, Pco2 29 mmHg, HCO3 19 mEq/L (19 mmol/L) 4. pH 7.33, Pco2 52 mmHg, HCO3 28 mEq/L (28 mmol/L)

3. pH 7.29, Pco2 29 mmHg, HCO3 19 mEq/L (19 mmol/L) Rationale: The client who has aspirin toxicity will manifest metabolic acidosis with respiratory compensation as seen when the pH is lower 7.35 mm Hg and the HCO3 is less than 22 mEq/L (22 mmol/L). In the correct option, the pH is acidotic and the HCO3 is decreased, indicating metabolic acidosis. The Pco2 is alkalotic, indicating partial compensation.

A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate effective teaching? 1. "I should use only my stomach and my thighs for injections." 2. "I need to use a different major site for each insulin injection." 3. "I should use the same major site for 1 month before rotating to another site." 4. "I need to give 4 to 6 injections in one area, about an inch apart, and then move to another area."

4. "I need to give 4 to 6 injections in one area, about an inch apart, and then move to another area." Rationale: The most efficient rotation plan involves giving about four to six injections in one area, each injection about 1 inch (2.5 cm) apart, or the diameter of the insulin vial from the previous injection, and then moving to another area of the major site the next day. All other options are incorrect.

The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse should tell the child to take which action? 1. Administer glucagon immediately if shakiness is felt. 2. Drink 8 ounces (235 ml) of diet cola at the first sign of weakness. 3. Report to a hospital emergency department if the blood glucose is 60 mg/dL (3.4 mmol/L). 4. Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.

4. Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs. Rationale: The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as Life Savers will provide a source of glucose. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a person unable to swallow who is experiencing a hypoglycemic reaction. A diet beverage is sugar free and will not be helpful. If the blood glucose level is 60 mg/dL (3.4 mmol/L), a source of glucose may be needed, but it is not necessary to report to the emergency department.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4. Checks the amount of urine output Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

A nurse is caring for an infant with a respiratory infection and is monitoring the infant for signs of dehydration. What is the nurse's best action to determine fluid loss in the infant? 1. Monitor body weight. 2. Obtain a temperature. 3. Monitor intake and output. 4. Assess the mucous membranes.

1. Monitor body weight. Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. The remaining options are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight.

The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment? 1. Oliguria 2. Flat fontanels 3. Pale skin color 4. Moist mucous membrane

1. Oliguria Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

2. It is negative. Rationale: Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (12.1 mcmol/L); (normal level is 0 to 2 mg/dL (0 to 121 mcmol/L). A result of 1 mg/dL is a negative test result.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs. Rationale: Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

4. Normal saline infusion Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the health care provider has documented that the infant is mildly dehydrated. Which assessment finding should the nurse expect to note in mild dehydration? 1. Anuria 2. Pale skin color 3. Sunken fontanels 4. Dry mucous membranes

2. Pale skin color Rationale: In mild dehydration the skin color is pale. Anuria and sunken fontanels are assessment characteristics of severe dehydration. Dry mucous membranes are an assessment characteristic of moderate dehydration.

The nurse has just administered ibuprofen to a child with a temperature of 102°F (38.8°C). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child. Rationale: After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

The nurse is teaching the parents of a child with growth hormone deficiency about preparing synthetic growth hormone and administering it to the child. Which statement, if made by the parents, would indicate an understanding of the procedure? 1. "We will rotate injection sites." 2. "We will give the injection weekly on Monday." 3. "We will administer the injection every morning." 4. "We will store the mixed growth hormone in the medicine cabinet."

1. "We will rotate injection sites." Rationale: Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection six or seven times per week as prescribed at bedtime. Parents are taught that, once diluted, the hormone preparation is to be stored at 36° to 46° F (refrigerated). Injection sites should be rotated, which will direct you to the correct option.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4. Fruity breath odor and decreasing level of consciousness Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

A child's fasting blood glucose levels range between 100 and 120 mg/dL (5.7 and 6.9 mmol/L) daily. The before-dinner blood glucose levels are between 120 and 130 mg/dL (6.9 and 7.4 mmol/L), with no reported episodes of hypoglycemia. Mixed insulin is administered before breakfast and before dinner. The nurse should make which interpretation about these findings? 1. Exercise should be increased to reduce blood glucose levels. 2. Insulin doses are appropriate for food ingested and activity level. 3. Dietary needs are being met for adequate growth and development. 4. Dietary intake should be increased to avoid hypoglycemic reactions.

2. Insulin doses are appropriate for food ingested and activity level. Rationale: Blood glucose levels are a measure of the balance among diet, medication, and exercise. Options 1 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here.

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4. Eat a small box of raisins or drink a cup of orange juice before soccer practice. Rationale: Hypoglycemia is a blood glucose level less than 70 mg/dL (4 mmol/L) and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.