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. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation.
B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority.
C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications.
D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
Correct Answer is D
Explanation
A. Fruity breath odor is associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Flushed skin is not a typical symptom of hypoglycemia.
C. Thirst is commonly associated with hyperglycemia.
D. Headache is a common symptom of hypoglycemia due to the lack of glucose supply to the brain.
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