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 C
Explanation
A. An axillary temperature of 37.3° C (99.1° F) is within the normal range for a child and does not need to be reported.
B. A respiratory rate of 24/min is within the normal range for a 6-year-old child and does not need to be reported.
C. A heart rate of 59/min is slightly below the normal range for a 6-year-old and should be reported to the provider.
D. A blood pressure of 96/58 mm Hg is within the normal range for a 6-year-old child and does not need to be reported.
Correct Answer is D
Explanation
A. Bedrest is not specifically required for children with varicella; activity should be based on the child's energy levels and comfort.
B. Bathing can be done carefully even with crusted lesions. Good hygiene can help prevent secondary infections.
C. If the guardian has had chickenpox, they are usually immune and do not need to wear a mask. The concern is more for immunocompromised individuals.
D. The child is no longer contagious once all the lesions have crusted over, making it safe to take them to the playroom.
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