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 A
Explanation
A. "You should bring the infant's favourite blanket to the hospital." Bringing the infant's favourite blanket can provide comfort and a sense of security in an unfamiliar hospital environment. It helps the child feel more at ease and can reduce anxiety and stress associated with hospitalization.
B. "You should begin to manipulate the infant's bedtime based on the hospital’s visiting hours." Disrupting the infant’s usual sleep routine can lead to increased stress and irritability. It is better to maintain familiar routines as much as possible to provide comfort and stability during the hospital stay.
C. "You should read the child a story about hospitalization." At 8 months, an infant may not comprehend stories about hospitalization. Reading stories is more effective for older children who can understand and process the information. The focus for infants should be on comfort and familiarity.
D. "You will need to go home when it is not visiting hours." Parents are typically encouraged to stay with their young children in the hospital whenever possible. Parental presence is crucial for the infant’s emotional well-being and can help reduce anxiety.
Correct Answer is A
Explanation
A. "Bend forward from the waist with your head and arms downward." This position, known as the Adam’s forward bend test, is commonly used to screen for scoliosis. It allows the nurse to observe for any asymmetry in the rib cage or spine, which could indicate scoliosis.
B. "Lie prone on the examination table." Lying prone (face down) does not allow for the assessment of spinal curvature or rib asymmetry. This position is not useful for scoliosis screening.
C. "Touch your chin to your chest, and then look up at the ceiling." These movements assess neck flexibility and range of motion, which are not relevant for screening scoliosis.
D. "Turn to the side, and remain in a relaxed position." Turning to the side and relaxing does not provide the necessary view of the spine to assess for scoliosis. This position does not allow for a clear view of any asymmetry in the spine or ribs.
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