A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.

Choice A rationale:

Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.

Choice B rationale:

A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.

Choice C rationale:

A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.

Choice D rationale:

Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.

The correct answer is Choice D: Obtain the client's weight.

Choice D rationale: Obtaining the client's weight is crucial in planning hemodialysis treatment, as it helps determine the amount of fluid that needs to be removed during the procedure. This information contributes to accurate calculation of the ultrafiltration rate, ensuring adequate fluid balance and preventing potential complications associated with fluid overload or excessive fluid removal.

Choice A rationale: Encouraging the client to increase fluid intake is not recommended in the context of hemodialysis, as excessive fluid intake may result in fluid overload, a common complication in patients undergoing this treatment. Instead, the nurse should advise the client on appropriate fluid restrictions, taking into account their individualized plan of care.

Choice B rationale: Reinforcing the practice of sleeping on the side of the access site is not advisable because it could lead to increased pressure on the arteriovenous fistula, potentially causing complications such as thrombosis or stenosis. It is generally recommended that clients avoid putting pressure on the access site, particularly during sleep or when engaging in activities that could cause direct contact with the area.

Choice C rationale: Obtaining the client's blood pressure in either arm is not the appropriate approach, as the arm with the arteriovenous fistula should not be used for blood pressure measurements or any other procedures that could damage the fistula. Blood pressure should be measured in the non-access arm to ensure the integrity of the vascular access and minimize the risk of complications.