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
meningitis.
hydrocephalus.
intracranial hemorrhage.
sepsis.
The Correct Answer is A
Choice A reason: Meningitis is a possible condition, as it is an inflammation of the membranes that cover the brain and spinal cord. It can be caused by various microorganisms, such as bacteria, viruses, or fungi. The infant has many signs and symptoms of meningitis, such as fever, irritability, lethargy, bulging fontanel, and clear cerebrospinal fluid from the lumbar puncture.
Choice B reason: Hydrocephalus is not a likely condition, as it is an accumulation of cerebrospinal fluid in the brain, which causes increased intracranial pressure and enlargement of the head. The infant has a bulging fontanel, which can indicate increased intracranial pressure, but not necessarily hydrocephalus. The infant does not have other signs of hydrocephalus, such as a rapidly increasing head circumference, prominent scalp veins, or sunset eyes.
Choice C reason: Intracranial hemorrhage is not a probable condition, as it is a bleeding within the skull, which can result from trauma, vascular malformation, or coagulation disorder. The infant has retinal hemorrhages, which can indicate intracranial hemorrhage, but not necessarily. The infant does not have other signs of intracranial hemorrhage, such as seizures, vomiting, or altered mental status.
Choice D reason: Sepsis is not a definite condition, as it is a systemic inflammatory response to an infection, which can cause organ dysfunction and shock. The infant has a fever, which can indicate sepsis, but not necessarily. The infant does not have other signs of sepsis, such as tachycardia, tachypnea, hypotension, or poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Broad-spectrum antibiotics are indicated for septic shock caused by bacterial infection, as they can target a wide range of pathogens and prevent further sepsis. Fluid boluses are also essential to restore the intravascular volume and improve tissue perfusion and oxygenation.
Choice B reason: Antipyretics and oxygen therapy are not sufficient to treat septic shock, as they do not address the underlying infection or the hypovolemia. Antipyretics may lower the temperature, but they do not eliminate the bacteria. Oxygen therapy may improve the pulse oximeter reading, but it does not correct the hypoperfusion.
Choice C reason: Vasopressors and blood transfusions are not the first-line treatments for septic shock, as they may have adverse effects on the cardiovascular system and the coagulation cascade. Vasopressors may increase the blood pressure, but they may also cause vasoconstriction and reduce the blood flow to vital organs. Blood transfusions may increase the hemoglobin level, but they may also increase the risk of fluid overload, hemolysis, and transfusion reactions.
Choice D reason: Corticosteroids and antihistamines are not indicated for septic shock, as they do not have any proven benefits and may have harmful effects on the immune system and the inflammatory response. Corticosteroids may suppress the adrenal function and increase the risk of infection. Antihistamines may cause sedation and dryness of the mucous membranes.
Correct Answer is B
Explanation
Choice A reason: Subcutaneous insulin is not the preferred route for a client with DKA, as it has a slower onset and peak than IV insulin. IV regular insulin is the preferred route, as it provides a rapid and continuous infusion of insulin that can be titrated according to the blood glucose level.
Choice B reason: IV regular insulin is the medication of choice for a client with DKA, as it lowers the blood glucose level and reverses the ketosis and acidosis. IV regular insulin has a rapid onset and peak, and can be adjusted based on the client's response.
Choice C reason: IV potassium chloride is indicated for a client with DKA, as the client is at risk of hypokalemia due to osmotic diuresis, insulin therapy, and metabolic acidosis. IV potassium chloride can prevent or treat hypokalemia and its complications, such as cardiac arrhythmias.
Choice D reason: Oxygen via nasal cannula is not necessary for a client with DKA, unless the client has signs of hypoxia or respiratory distress. The client's deep and rapid respirations are a compensatory mechanism for the metabolic acidosis, and do not indicate a need for oxygen therapy.
Choice E reason: Sodium bicarbonate is not recommended for a client with DKA, as it can cause paradoxical cerebral acidosis, hypokalemia, and impaired oxygen delivery. The client's acidosis can be corrected by IV insulin and fluid therapy, which will restore the normal metabolism of glucose and ketones.
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