A nurse is assisting in the care of an 8-month-old infant.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Drawing a blood culture is not indicated for suspected Clostridium difficile, as it is a gastrointestinal infection.
B. A stool specimen for occult blood is not specific for diagnosing Clostridium difficile.
C. Obtaining a stool specimen for culture is the appropriate action to diagnose Clostridium difficile, as it will identify the presence of the bacteria.
D. A tape test is used to detect pinworms, not Clostridium difficile.

A. A 6-year-old child who has a fracture of the arm from a bicycle injury B. A 34-month-old child who has several small bruises on the shins C. A 4-year-old child who has a history of frequent urinary tract infections D. A 15-month-old child who bites other children while at day care

Correct Answer is C

Explanation

A. A fracture from a bicycle injury is consistent with common childhood accidents and does not necessarily indicate maltreatment.
B. Small bruises on the shins of a toddler are typical as they learn to walk and play and are not necessarily a sign of maltreatment.
C. Frequent urinary tract infections in a young child can be a sign of sexual abuse or neglect and should be reported for further investigation. This pattern is concerning and warrants further evaluation by a healthcare provider.
D. Biting behavior in toddlers is relatively common and part of normal development. It does not necessarily indicate maltreatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler whose guardian reports multiple episodes of diarrhea. The provider suspects Clostridium difficile. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in a well-child clinic is collecting data from four clients. Which of the following findings should the nurse report to the provider as a potential indication of child maltreatment?

Correct Answer is C

Explanation

A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

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A nurse is collecting data from a 3-month-old infant. Which of the following is an expected developmental finding?

A nurse is monitoring the vital signs of a 6-year-old child following a surgical procedure. Which of the following findings should the nurse report to the provider?

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A nurse is reinforcing teaching with a parent of a school-age child who is being discharged following a cardiac catheterization. Which of the following statements by the parent indicates an understanding of the teaching?

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A nurse is reviewing the medical records of a group of clients. Which of the following findings should the nurse report to local authorities?