Saunders VI ch 33
A parent brings a 2-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.
Answer: 2 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 (1210 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.
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/hr.
Answer: 3 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/hr, 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/hr, a specific gravity of 1.035, and no tears would indicate that the deficit is not resolving.
The parents of a 6-year-old child who has type 1 diabetes mellitus call a clinic nurse and tell the nurse that the child has been sick. The parents report that the child's urine is positive for ketones. The nurse would instruct the parents 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
Answer: 3 Rationale: When the child is sick, the parents need to test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child would be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses would not be adjusted or changed.
The nurse would 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
Answer: 3, 6 Rationale: Hypoglycemia is defined as a blood glucose level of 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 needs to 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 needs to 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.
The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse would 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.
Answer: 4 Rationale: After administering ibuprofen, excess clothing and blankets need to be removed. The child would not be sponge bathed, especially with cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin (a salicylate) 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 would not be withheld
A child with type 1 diabetes mellitus is brought to the emergency department by the parents, who state 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
Answer: 4 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.
An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings would 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
Answer: 4 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 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 would 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.
Answer: 4 Rationale: Hypoglycemia is a blood glucose level of 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 would not be instructed to adjust the amount or time of insulin administration. Meal amounts would not be doubled.
A pediatrician 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
Answer: 4 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 would never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride would 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.
