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","B","C","D"]
Explanation
Choice A reason: This is a finding that the nurse should report to the provider. A pressure dressing is applied to the site of the catheter insertion to prevent bleeding and hematoma formation. If the dressing is saturated with bloody drainage, it indicates that the bleeding is not controlled and may lead to hemorrhage or infection.
Choice B reason: This is a finding that the nurse should report to the provider. Pulses of the extremity where the catheter was inserted should be equal to or stronger than the other extremity. If the pulses are diminished, it indicates that there is impaired blood flow to the extremity, which may be caused by arterial occlusion, thrombosis, or vasospasm.
Choice C reason: This is a finding that the nurse should report to the provider. The color and temperature of the extremity where the catheter was inserted should be similar to the other extremity. If the extremity is cool and pale, it indicates that there is inadequate perfusion to the extremity, which may be caused by the same factors as the diminished pulses.
Choice D reason: This is a finding that the nurse should report to the provider. Pain is an indicator of tissue damage or inflammation. The adolescent should have minimal or no pain after the procedure, as the site is numbed with local anesthesia. If the pain is present or increases, it indicates that there is a complication, such as bleeding, infection, or nerve injury.
Choice E reason: This is not a finding that the nurse should report to the provider. The apical pulse is the heart rate measured at the apex of the heart. It is a routine vital sign that the nurse should monitor after the procedure, but it is not a sign of a complication unless it is abnormal, such as too fast, too slow, or irregular. The nurse should compare the apical pulse with the baseline and the expected range for the adolescent's age and condition.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Balancing the scale to 0 prior to use is a correct action for the nurse to take. This ensures that the scale is accurate and does not include any extra weight from the scale itself or any objects on it.
Choice B reason: Using a stadiometer to measure the infant is not a correct action for the nurse to take. A stadiometer is a device that measures the height of a standing person. It is not suitable for measuring the length of an infant who cannot stand. The nurse should use a measuring board or a tape measure to measure the infant's length.
Choice C reason: Placing a disposable covering on the scale is a correct action for the nurse to take. This prevents the transmission of germs or dirt from the scale to the infant or vice versa. It also protects the scale from any urine or stool that the infant may produce during the weighing.
Choice D reason: Weighing the infant in a diaper is not a correct action for the nurse to take. A diaper can add extra weight to the infant's measurement and affect the accuracy of the result. The nurse should weigh the infant without any clothing or diaper.
Choice E reason: Measuring the infant from crown of the head to the heels of feet is a correct action for the nurse to take. This is the standard method of measuring the length of an infant. The nurse should place the infant on a flat surface, align the head with the top of the measuring board or tape measure, and extend the legs fully. The nurse should then read the measurement at the bottom of the infant's feet.
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