A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) All of the above. Failure to thrive (FTT) in infants is a serious condition characterized by inadequate weight gain and growth. Infants with FTT may exhibit signs such as fear of strangers, minimal smiling, and avoidance of eye contact. These behavioral and social cues can be indicative of underlying issues affecting the infant's growth and development. Option A) Fear of strangers is relevant because infants with FTT may display heightened anxiety and fear around unfamiliar individuals due to the lack of consistent nurturing and attachment. Option B) Minimal smiling is significant as infants typically smile in response to positive interactions and stimuli. In cases of FTT, the infant's limited engagement and lack of joy may signal underlying concerns impacting their emotional well-being. Option C) Avoidance of eye contact is also pertinent as it can indicate difficulties in forming secure attachments and bonding with caregivers, which are crucial for healthy social and emotional development in infants. Educationally, understanding the assessment findings associated with FTT is vital for nurses caring for pediatric patients. Recognizing these behavioral cues can prompt early intervention and appropriate support services to address the underlying factors contributing to FTT in infants. By identifying and addressing these signs early, healthcare providers can work towards promoting optimal growth, development, and well-being in infants at risk for FTT.

Correct Answer: B

Rationale: In this question about potential causes of colic in infancy, the correct answer is B) All are applicable. The educational rationale behind this answer is that colic in infants can have multiple contributing factors, and it is often a multifactorial issue. Overeating can lead to digestive discomfort which can contribute to colic. Frequent burping helps release trapped gas which can alleviate colic symptoms. Parental smoking exposes infants to harmful chemicals that can irritate their sensitive systems and exacerbate colic. Option A, overeating, is a common misconception as infants typically have regulated feeding patterns. Option C, frequent burping, is important for relieving gas but is not the sole cause of colic. Option D, parental smoking, is a significant risk factor for colic due to exposure to secondhand smoke. Educationally, this question emphasizes the importance of understanding the various factors that can contribute to colic in infants. It highlights the need for comprehensive teaching to parents on how to address and prevent colic by considering multiple aspects of infant care, including feeding, burping techniques, and environmental factors like parental smoking.

Correct Answer: B

Rationale: The most appropriate nursing action in this scenario is to direct the father to seek immediate medical treatment (Option B). Visine eye drops contain tetrahydrozoline, which when ingested can lead to serious consequences like decreased heart rate, decreased body temperature, respiratory depression, seizures, coma, and even death, especially in young children. Seeking medical treatment promptly is crucial to prevent these adverse effects and ensure proper management. Reassuring the father that Visine is harmless (Option A) is incorrect as it conveys a dangerous message that could lead to delayed treatment. Recommending inducing vomiting with ipecac (Option C) is not recommended due to the risks associated with ipecac use and the potential for aspiration. Advising to dilute Visine by giving the daughter several glasses of water (Option D) is also not appropriate as it does not address the potential serious effects of tetrahydrozoline ingestion. In an educational context, it is important for nurses to recognize the potential dangers of household items like eye drops and to provide accurate and timely information to parents and caregivers. This scenario highlights the importance of quick assessment and appropriate action in cases of potential poisoning, emphasizing the critical role nurses play in promoting patient safety and advocacy.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Edema of the lips, tongue, and pharynx. This clinical manifestation is most suggestive of ingestion of a corrosive product because corrosive substances can cause significant swelling and edema of the mucous membranes they come into contact with. This is a localized reaction that occurs due to the corrosive nature of the substance damaging the tissues. Option A) Tinnitus, and Option B) Disorientation are not typical clinical manifestations associated with ingestion of corrosive products. Tinnitus is a ringing in the ears and is not directly related to corrosive ingestion. Disorientation can be a symptom of poisoning, but it is not specific to corrosive substances. Option C) Stupor, lethargy, and coma are more commonly associated with central nervous system depressants or toxins affecting the brain rather than corrosive substances which primarily cause local tissue damage. In an educational context, understanding the specific clinical manifestations of different types of poisonings is crucial for nurses caring for children. Recognizing the signs of corrosive ingestion can prompt swift and appropriate intervention to prevent further damage and improve outcomes for the child. Nurses must be knowledgeable about the effects of various toxins to provide safe and effective care to pediatric patients.

Correct Answer: B

Rationale: In the context of acetaminophen poisoning, the correct clinical manifestation is hepatic involvement (Answer B). Acetaminophen toxicity primarily affects the liver, leading to hepatic necrosis and liver failure. This is a crucial clinical sign to recognize as prompt treatment is essential to prevent severe complications and potential death. Option A (Hyperpyrexia) is incorrect because acetaminophen poisoning typically does not cause high fever. Option C (Severe burning pain in stomach) is also incorrect as acetaminophen toxicity may cause abdominal pain but not specifically described as severe burning pain. Option D (Drooling and inability to clear secretions) is unrelated to acetaminophen poisoning and may be seen in other conditions affecting the respiratory and salivary systems. In an educational context, understanding the clinical manifestations of acetaminophen poisoning is vital for nurses caring for children. Recognizing these signs early can prompt timely interventions and prevent further harm. Nurses should also be aware of the importance of accurate medication dosing to prevent accidental acetaminophen toxicity in pediatric patients.