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. Drawing a blood culture is not indicated for suspected Clostridium difficile, as it is a gastrointestinal infection.
B. A stool specimen for occult blood is not specific for diagnosing Clostridium difficile.
C. Obtaining a stool specimen for culture is the appropriate action to diagnose Clostridium difficile, as it will identify the presence of the bacteria.
D. A tape test is used to detect pinworms, not Clostridium difficile.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should clarify the child's prescription of dextrose 5% in 0.45% sodium chloride with 20 mEq potassium chloride/L at 75 mL/hr because of the child's laboratory values. The elevated potassium level of 6.2 mEq/L, which is above the normal range of 3.4 to 4.7 mEq/L, indicates hyperkalemia. Administering additional potassium could exacerbate this condition, therefore, it is crucial to review the prescription and adjust it accordingly to ensure the safety and well-being of the child.
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