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 ["B"]
Explanation
Choice A reason: Polyuria, or excessive urination, is not a sign of low blood glucose level, but of high blood glucose level. It is caused by osmotic diuresis, which occurs when the kidneys try to flush out the excess glucose from the blood.
Choice B reason: Tachycardia, or fast heart rate, is a sign of low blood glucose level. It is caused by the activation of the sympathetic nervous system, which releases adrenaline and other hormones to increase the blood glucose level and stimulate the heart.
Choice C reason: Dry, flushed skin is not a sign of low blood glucose level, but of high blood glucose level. It is caused by dehydration, which occurs when the body loses fluid due to polyuria and increased thirst.
Choice D reason: Deep, rapid respirations are not a sign of low blood glucose level, but of diabetic ketoacidosis, a complication of high blood glucose level. It is caused by the accumulation of ketones, which are acidic substances produced when the body breaks down fat for energy due to lack of insulin.
Choice E reason: Hunger is a sign of low blood glucose level. It is caused by the lack of glucose in the cells, which are the main source of energy for the body. The brain signals the body to eat more to raise the blood glucose level.
Correct Answer is A
Explanation
Choice A reason: Intravenous immunoglobulin is a likely prescription, as it is used to treat Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels in children. The toddler has many signs and symptoms of Kawasaki disease, such as high fever, irritability, red eyes, dry lips, strawberry tongue, swollen hands and feet, rash, and enlarged lymph node. Intravenous immunoglobulin can reduce the risk of complications, such as coronary artery aneurysms, which can be life-threatening.
Choice B reason: Oral acyclovir is not a probable prescription, as it is used to treat viral infections, such as herpes simplex or varicella zoster, which are not the main problems of the toddler. The toddler has no evidence of a viral infection, such as blisters, vesicles, or crusts.
Choice C reason: Intramuscular penicillin is not a likely prescription, as it is used to treat bacterial infections, such as streptococcal pharyngitis or syphilis, which are not the main problems of the toddler. The toddler has no signs of a bacterial infection, such as purulent discharge, foul odor, or localized inflammation.
Choice D reason: Topical hydrocortisone is not a helpful prescription, as it is used to treat skin conditions, such as eczema or dermatitis, which are not the main problems of the toddler. The toddler has a rash that is caused by the inflammation of the blood vessels, not by an allergic or irritant reaction. Topical hydrocortisone may also worsen the rash or cause skin thinning or infection.
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