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
failure to thrive.
microcephaly.
hydrocephalus.
macrocephaly.
The Correct Answer is C
Choice A reason: Failure to thrive is not a likely condition, as it is a term used to describe inadequate growth or weight gain in children. The infant has a low weight percentile, but not below the 5th percentile, which is the usual cutoff for failure to thrive. The infant's length and head circumference are within the normal range, which also does not indicate failure to thrive.
Choice B reason: Microcephaly is not a probable condition, as it is a condition where the head size is much smaller than normal for the age and sex of the child. The infant has a high head circumference percentile, which is the opposite of microcephaly. Microcephaly can be caused by genetic disorders, infections, or brain damage.
Choice C reason: Hydrocephalus is a possible condition, as it is a condition where excess cerebrospinal fluid accumulates in the brain, causing increased pressure and enlargement of the head. The infant has a high head circumference percentile, which can indicate hydrocephalus. The infant also has a low weight percentile, which can be a result of poor feeding or vomiting due to increased intracranial pressure. T
Choice D reason: Macrocephaly is not a definite condition, as it is a term used to describe a head size that is much larger than normal for the age and sex of the child. The infant has a high head circumference percentile, but not above the 97th percentile, which is the usual cutoff for macrocephaly. Macrocephaly can be caused by genetic factors, benign familial macrocephaly, or other conditions, such as hydrocephalus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Weight loss is not a typical finding in a toddler who has heart failure. Weight gain due to fluid retention is more likely to occur. The nurse should monitor the toddler's weight and fluid intake and output regularly.
Choice B reason: Bradycardia is not a typical finding in a toddler who has heart failure. Tachycardia due to increased cardiac workload is more likely to occur. The nurse should monitor the toddler's heart rate and rhythm frequently.
Choice C reason: Increased urine output is not a typical finding in a toddler who has heart failure. Decreased urine output due to poor renal perfusion is more likely to occur. The nurse should monitor the toddler's urine specific gravity and electrolytes periodically.
Choice D reason: Orthopnea is a typical finding in a toddler who has heart failure. Orthopnea is the difficulty of breathing when lying flat. The nurse should elevate the toddler's head and chest to facilitate breathing and oxygenation.
Correct Answer is B
Explanation
Choice A reason: Fifth disease is a viral infection that causes a rash on the face and body. It is also known as erythema infectiosum or slapped cheek syndrome. It is not the same as pertussis.
Choice B reason: Whooping cough is a bacterial infection that causes severe coughing spells that end with a whooping sound. It is also known as pertussis or the 100-day cough. It is the correct common name for the disease.
Choice C reason: Chickenpox is a viral infection that causes an itchy rash with blisters. It is also known as varicella. It is not the same as pertussis.
Choice D reason: Mumps is a viral infection that causes swelling of the salivary glands. It is also known as parotitis. It is not the same as pertussis.
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