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 A
Explanation
A. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.
Correct Answer is B
Explanation
A. An oatmeal bath can soothe the skin but is not the immediate first step.
B. Flushing the area with cold, running water helps remove the plant oils that cause the reaction and is the first step in managing poison ivy exposure.
C. Administering an oral corticosteroid may be necessary for severe reactions but is not the first action to take.
D. Calamine lotion can help with itching but should be applied after washing off the plant oils.
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