The nurse is caring for a 4-month-old infant in the emergency department. The nurse reviews the infant's medical record and assessment findings. Which of the following conditions should the nurse suspect, and what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the infant's progress?
The nurse should suspect that the infant has
failure to thrive.
microcephaly.
hydrocephalus.
macrocephaly.
The Correct Answer is C
Choice A reason: Failure to thrive is not a likely condition, as it is a term used to describe inadequate growth or weight gain in children. The infant has a low weight percentile, but not below the 5th percentile, which is the usual cutoff for failure to thrive. The infant's length and head circumference are within the normal range, which also does not indicate failure to thrive.
Choice B reason: Microcephaly is not a probable condition, as it is a condition where the head size is much smaller than normal for the age and sex of the child. The infant has a high head circumference percentile, which is the opposite of microcephaly. Microcephaly can be caused by genetic disorders, infections, or brain damage.
Choice C reason: Hydrocephalus is a possible condition, as it is a condition where excess cerebrospinal fluid accumulates in the brain, causing increased pressure and enlargement of the head. The infant has a high head circumference percentile, which can indicate hydrocephalus. The infant also has a low weight percentile, which can be a result of poor feeding or vomiting due to increased intracranial pressure. T
Choice D reason: Macrocephaly is not a definite condition, as it is a term used to describe a head size that is much larger than normal for the age and sex of the child. The infant has a high head circumference percentile, but not above the 97th percentile, which is the usual cutoff for macrocephaly. Macrocephaly can be caused by genetic factors, benign familial macrocephaly, or other conditions, such as hydrocephalus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a correct statement by the child. The child should take their regular insulin as prescribed, even when they are sick. Insulin helps the body use glucose for energy and prevents high blood sugar levels, which can cause complications. The child may need to adjust their insulin dose or frequency depending on their blood glucose levels, food intake, and activity level.
Choice B reason: This is not a correct statement by the child. The child should not store unopened bottles of insulin in the freezer. Freezing can damage the insulin and make it ineffective. The child should store unopened bottles of insulin in the refrigerator, away from direct light and heat. The child should store opened bottles of insulin at room temperature and discard them after 28 days.
Choice C reason: This is not a correct statement by the child. The child's morning blood glucose should be between 70 and 110 mg/dL, according to the American Diabetes Association. A blood glucose level between 90 and 130 mg/dL may indicate that the child has hyperglycemia, or high blood sugar, which can cause symptoms such as thirst, hunger, fatigue, and frequent urination.
Choice D reason: This is a correct statement by the child. The child should eat a snack half an hour before playing soccer or engaging in any physical activity. Physical activity lowers blood glucose levels, and a snack can help prevent hypoglycemia, or low blood sugar, which can cause symptoms such as shakiness, sweating, dizziness, and confusion.
Correct Answer is C
Explanation
Choice A reason: Offering the child clear liquids for the first 24 hours is not necessary, as the child can resume a normal diet after the procedure. Clear liquids are only recommended for the first few hours after the procedure to prevent nausea and vomiting.
Choice B reason: Assisting the child to take a tub bath for the first 3 days is not advised, as it can increase the risk of infection and bleeding at the catheter insertion site. The child should avoid tub baths, swimming, and soaking the site until it is completely healed, which may take up to a week.
Choice C reason: Giving the child acetaminophen for discomfort is appropriate, as it can relieve the pain and soreness at the catheter insertion site. The child should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as they can increase the risk of bleeding.

Choice D reason: Keeping the child home for 1 week is not required, as the child can resume normal activities within a few days after the procedure. The child should avoid strenuous activities, such as running, jumping, and biking, for at least 24 hours after the procedure.
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