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 C
Explanation
a. Mix the medication with the child's favorite food. Mixing medication with a child’s favorite food can be risky as it may alter the taste of the food and cause the child to develop an aversion to that food. Additionally, if the child does not consume the entire portion, they may not receive the full dose of medication.
b. Dilute the medication with 8 oz of water. Diluting medication in a large volume of water is not advisable for a preschooler as it may be difficult for them to drink the entire amount, leading to an incomplete dose. It can also dilute the medication to the point where its efficacy is reduced.
c. Provide an ice pop after administering the medication. Offering an ice pop after administering the medication is a positive reinforcement technique. The ice pop can also help numb the taste buds, reducing the aftertaste of the medication, making it more acceptable for the child.
d. Give 4 oz of milk with the medication.Giving milk with medication is not generally recommended as it can interfere with the absorption of some medications. Additionally, if the medication tastes unpleasant, the child might refuse to drink the milk as well.
Correct Answer is A
Explanation
A. Maculopapular skin burrows on the hand. Correct. Scabies is characterized by burrows in the skin, often seen as small, wavy, thread-like lesions, commonly found on the hands, between fingers, and on wrists.
B. Scaly lesions on the inner thighs. Incorrect. While scaly lesions can be present in various skin conditions, they are not typical of scabies.
C. Bull's eye edematous area on the groin. Incorrect. This description is more characteristic of Lyme disease, not scabies.
D. Rash with red macular lesions on the scalp. Incorrect. Scabies does not typically affect the scalp, especially in older children and adults.
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