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 D
Explanation
A. Inform the client to contact the pharmacy regarding any questions related to the medication. While pharmacists can provide additional information, the nurse should ensure the adolescent understands the medication instructions and has immediate answers to any questions during the teaching session.
B. Provide instructions to the client's parent with the client present. Adolescents may be more comfortable discussing sensitive topics such as STIs privately. The primary teaching should be directed to the adolescent to respect their autonomy and privacy.
C. Instruct the client's parents to write down the information that is being provided. This is not appropriate for an adolescent who is capable of understanding their own medical information. The focus should be on ensuring the adolescent comprehends the information.
D. Ask how the client prefers to learn new information. Correct. Asking the adolescent how they prefer to learn new information helps tailor the education to their learning style, making it more effective and respectful of their preferences.
Correct Answer is B
Explanation
A. "Hemodialysis uses an electrolyte solution to clean your child's blood." Hemodialysis does not use an electrolyte solution to clean the blood. Instead, it uses a dialysate, a special fluid that helps remove waste products and excess substances from the blood through a semi-permeable membrane in the dialyzer.
B. "Hemodialysis uses an artificial membrane outside the body to clean your child's blood." This statement is accurate. Hemodialysis involves passing the child's blood through an artificial membrane (dialyzer) outside the body to filter and clean it, removing waste products and excess fluids.
C. "Hemodialysis uses your child's abdominal cavity as a membrane to clean their blood." This statement describes peritoneal dialysis, not hemodialysis. In peritoneal dialysis, the peritoneal cavity inside the abdomen is used as a natural membrane for dialysis.
D. "Hemodialysis slowly filtrates your child's blood continuously." Continuous slow filtration of blood describes Continuous Renal Replacement Therapy (CRRT), not standard hemodialysis. Hemodialysis is typically performed several times a week for a few hours each session.
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