A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?
Constipation
Depressed anterior fontanel
Presence of the rooting reflex
High-pitched cry
The Correct Answer is D
D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.
A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.
B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.
C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ice pops are often recommended after tonsillectomy to help soothe the throat and provide hydration.
B.Although ice cream is cold and can soothe the throat, it is not the best option immediately after surgery. Dairy products, including ice cream, can sometimes lead to increased mucus production, which could irritate the throat and make swallowing more difficult during the healing process.
C. Offering hot tea is not recommended immediately following a tonsillectomy. Hot beverages, including tea, can increase the risk of bleeding and discomfort at the surgical site.
D. Cranberry juice is not an appropriate choice immediately post-tonsillectomy. While hydration is essential for recovery, acidic or tart beverages like cranberry juice may irritate the surgical site and increase discomfort.
Correct Answer is B
Explanation
B. The narrowing of the aorta results in increased resistance to blood flow beyond the constriction, leading to decreased blood pressure in the lower body, including the legs. As a result, the blood pressure in the arms may be significantly higher than in the legs, creating a notable blood pressure gradient between the upper and lower extremities.
A. Pulmonary edema is not a typical manifestation of coarctation of the aorta. Coarctation of the aorta involves a narrowing of the aortic arch, typically occurring after the branching of the vessels supplying the upper body.
C. Severe cyanosis is not typically associated with coarctation of the aorta. Cyanosis, a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood, is more commonly seen in conditions affecting pulmonary circulation or oxygenation of the blood, such as congenital heart defects involving right-to-left shunting of blood.
D. A machine-like murmur is not a typical finding in coarctation of the aorta. The characteristic murmur associated with coarctation of the aorta is a systolic ejection murmur heard best over the back or left axilla.
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