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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A: The reason why the child is taking the medication
It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.
Choice B: The adverse effects of the medication
Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.
Choice C: Stopping the medication when the child feels better
This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.
Choice D: Written information about the medication
Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.
Choice E: Using a kitchen spoon to administer the medication
This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.
Correct Answer is B
Explanation
Choice A reason: Changes in the voice signal the beginning of puberty is incorrect, as voice changes usually occur in the middle or late stages of puberty, not the beginning. The first sign of puberty in boys is usually testicular enlargement, followed by pubic hair growth and penile enlargement.
Choice B reason: Growth spurts in height occur toward the end of mid-puberty is correct, as this is the typical pattern of growth for boys during puberty. Boys usually start their growth spurt later than girls, but grow faster and for a longer period of time.
Choice C reason: Puberty might be delayed if scrotal changes have not occurred by the age of 11 years is incorrect, as this is not a definitive indicator of delayed puberty. Puberty can vary widely among individuals, and some boys may start later than others without any underlying problem. Delayed puberty is usually diagnosed if there is no sign of puberty by the age of 14 years.
Choice D reason: Gynecomastia commonly occurs during late puberty is incorrect, as gynecomastia, or the enlargement of breast tissue in males, usually occurs in the early or middle stages of puberty, not the late stage. It is caused by hormonal changes and usually resolves on its own within a few months or years.
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