A nurse is assisting in the care of an 8-month-old infant.
Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters where the nurse should collect data to monitor the infant's progress.
The Correct Answer is []
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Corticosteroid ointment is not recommended for viral conjunctivitis as it can exacerbate the infection or prolong the healing process. Viral conjunctivitis typically resolves on its own without the need for corticosteroids.
B. Cleaning the eye by wiping downward and outward from the inner canthus helps to remove discharge and prevent the spread of infection. This technique ensures that contaminants are removed efficiently and reduces the risk of re-infection.
C. Antibiotic eye ointment is not indicated for viral conjunctivitis, as antibiotics are ineffective against viruses. Treatment typically focuses on symptom relief rather than antibacterial therapy.
D. While cool compresses can provide symptom relief, continuous application is not necessary. Intermittent cool compresses may help to soothe irritation and reduce swelling, but continuous use is not required.
Correct Answer is B
Explanation
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
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