Health Promotion and Maintenance
93. A school-age child visits a school nurse with complaints of dizziness and shaking. The nurse confirms that the child has a history of type 1 diabetes mellitus when the child becomes diaphoretic and begins to faint. What should be the nurse's first action?
. Administer an injection of glucagon.
. Activate EMS.
. Squeeze glucose gel into the cheek.
. Test the child's blood sugar.
Test-Taking Tip
The key piece of information in the stem of the question is that the child is beginning to lose consciousness. A nurse must act quickly in this situation and assume that it is due to low blood sugar, because waiting to differentiate between hyper- and hypoglycemia could be life-threatening.
Content Area: Child Health, Endocrine; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is correct because the child is demonstrating symptoms of severe hypoglycemia and the nurse must administer an emergency dose of glucagon to prevent the child from going into shock. Answer 2 is incorrect because the nurse should first administer the emergency dose of glucagon, then contact emergency medical services (EMS). Answer 3 is incorrect because the child is becoming unresponsive, and placing anything into the mouth would be contraindicated due to the risk of aspiration. Answer 4 is incorrect because the child has sufficient symptoms of hypoglycemia that need immediate treatment.