A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
Low-pitched cry
Positive Babinski reflex
Insomnia
Bulging fontanel
The Correct Answer is D
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.
B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.
C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.
D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.
Correct Answer is ["6.4"]
Explanation
Convert the child's weight from pounds to kilograms:
Weight in pounds: 30 lb
Conversion: 1 lb ≈ 0.454 kg
Weight in kg: 30 lb× 0.454 kg/lb =13.62 kg
30lb×0.454kg/lb=13.62kg
Calculate the dose in mg:
Dose: 15 mg/kg
15 mg/kg ×13.62kg=204.3 mg
Determine the volume to administer:
Available concentration: 160 mg/5 mL
Volume in mL:
204.3 mg ÷160 mg/5mL
= 204.3mg×5ml ÷160mg
=6.4mL
The nurse should administer 6.4 mL of acetaminophen.
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