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. Driving skills can be impaired when friends are present due to distractions, which increases the risk of accidents and should be emphasized in safety teaching.
B. Sun protection is necessary even when using self-tanning creams, as they do not provide UV protection.
C. Medroxyprogesterone does not provide protection against gonorrhea or any other sexually transmitted infections; it is a contraceptive.
D. The risk of injury from firearms can actually increase during adolescence due to risk-taking behaviors and access to firearms.
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