Patient Data

Exhibits

Review H and P, nurse's note, flow sheet, and prescriptions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Infuse normal saline intravenously. B. Apply external cooling blanket. C. Provide a bottle of electrolyte solution. D. Administer an antipyretic rectally.

Correct Answer is A

Explanation

A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.

B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.

C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.

D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) trichomoniasis who reports having had unprotected sex. Which response should the nurse provide?

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea, Which source of contamination should the nurse consider when interviewing the client about exposure?

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.