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","D","E"]
Explanation
A. Decreased cardiac output in heart failure can lead to poor perfusion of the extremities, resulting in cool skin and decreased urine output due to reduced renal perfusion and impaired kidney function.
D. Poor feeding is often observed due to increased respiratory effort, tachypnea, and fatigue associated with heart failure. Additionally, infants may exhibit failure to thrive or inadequate weight gain despite increased caloric intake due to metabolic demands and inefficient utilization of nutrients.
E. Tachypnea and respiratory distress occur due to pulmonary congestion and increased respiratory effort in response to heart failure. Infants may exhibit signs such as nasal flaring, grunting, retractions, and cyanosis.
B. Bradycardia and hypotension are not typical manifestations of heart failure in infants. Instead, infants with heart failure often present with tachycardia (rapid heart rate) as a compensatory mechanism to maintain cardiac output. Hypotension may occur in severe cases but is not a common finding.
C. Increased appetite and excessive weight gain are not typical manifestations of heart failure in infants. Infants with heart failure often experience poor feeding and failure to thrive due to inadequate cardiac output and oxygen delivery to meet metabolic demands.
Correct Answer is ["A","D"]
Explanation
A. Corticosteroids help reduce airway inflammation during an asthma exacerbation, which can help improve breathing and reduce symptoms.
D. Bronchodilator medications, such as albuterol, help relax the muscles around the airways, making it easier to breathe during an asthma exacerbation. They are typically used as rescue medications to provide immediate relief of asthma symptoms.
B. Placing the client in a supine position (lying flat on their back) is not recommended during an asthma exacerbation. This position can make breathing more difficult for someone experiencing respiratory distress.
C. Vigorous physical activity can exacerbate asthma symptoms and trigger an asthma attack. During an asthma exacerbation, it's important to encourage the client to rest and avoid strenuous activities that could worsen their breathing difficulties.
E. Cold compresses are not recommended for asthma exacerbations. Warm, moist air may help loosen mucus and ease breathing, but cold compresses could potentially exacerbate symptoms or discomfort.
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