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. Administering bronchodilator therapy immediately before chest physiotherapy helps open the airways, making the therapy more effective.
B. Administering the bronchodilator 2 hours before is too early to have the desired effect during physiotherapy.
C. Administering the bronchodilator 2 hours after does not support the immediate effectiveness of chest physiotherapy.
D. Administering the bronchodilator immediately after chest physiotherapy does not provide the benefit needed during the procedure.
Correct Answer is A
Explanation
A. Ensuring the child’s arm doesn’t hang down for extended periods can help prevent swelling and discomfort.
B. Submerging a fiberglass cast can damage the material and is not recommended.
C. It is important to encourage the child to move their fingers to maintain circulation and prevent stiffness.
D. Using a pencil to scratch inside the cast can cause injury or damage to the skin and should be avoided.
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