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 B
Explanation
A. A slight fever is not typically expected after a lumbar puncture and could indicate an infection or other complication that needs to be addressed.
B. It is important to keep the child's head flat for several hours after the procedure to prevent post-lumbar puncture headaches and other complications.
C. Increasing fluid intake is encouraged after a lumbar puncture to help prevent headaches and promote recovery. Fluid restriction is not indicated.
D. Numbness in the legs is not a common side effect of a lumbar puncture. Any numbness or neurological changes should be reported immediately as they could indicate a complication.
Correct Answer is A
Explanation
A. "You should be prepared to answer your child's questions about dying." is appropriate because children at this age may have questions about death and dying. It is important for the guardian to be honest and provide age-appropriate answers to help the child understand and cope with their situation.
B. While younger children often view death as temporary, a 10-year-old child typically has a more developed understanding of the finality of death. This statement might not be accurate for this age group.
C. Hiding grief is not recommended as it can create an atmosphere of secrecy and fear. It is better to model healthy expressions of emotions and provide support for the child's feelings.
D. Limiting visits between siblings may not be necessary and can be detrimental. Sibling support can be very important for both the ill child and the sibling, providing comfort and a sense of normalcy.
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