A nurse in a pediatric intensive care unit is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of neurological impairment?
The child's oxygen saturation is 96% on room air.
The child reports pain as 8 on a scale of 0 to 10.
The child is drowsy but responds immediately to verbal stimuli.
The child's blood pressure is 100/60 mm Hg.
The Correct Answer is C
A. The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Tachycardia: Tachycardia (increased heart rate) is a common compensatory mechanism in heart failure as the heart tries to pump more effectively.
B. Dyspnea: Dyspnea is a common symptom of heart failure due to fluid accumulation in the lungs.
C. Weight loss: Weight gain, rather than weight loss, is more commonly associated with heart failure due to fluid retention. Therefore, weight loss is not an expected finding.
D. Cyanosis: Cyanosis can occur in heart failure due to poor oxygenation and circulation.
E. Bounding peripheral pulses: Bounding peripheral pulses are not typically associated with heart failure. Heart failure often results in weak or thready pulses due to poor cardiac output.
Correct Answer is B
Explanation
A. A 3-year-old child with a newly applied cast for a fractured arm who stutters: Stuttering in a 3-year-old is not an immediate indicator for an auditory evaluation unless accompanied by other signs of hearing issues.
B. A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis: Bacterial meningitis can lead to hearing loss, so an auditory evaluation is appropriate for this infant to assess for any hearing impairment resulting from the infection.
C. A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis: Erythromycin use is not typically associated with hearing loss. The focus should be on monitoring recovery from pertussis.
D. A 6-month-old infant who is experiencing loose stools and is babbling loudly: Loose stools and babbling are not related to hearing issues and do not indicate the need for an auditory evaluation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.