A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?

Choice A rationale:

Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.

Choice B rationale:

Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.

Choice C rationale:

Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.

Choice D rationale:

Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.