A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP) Which of the following manifestations should the nurse expect?
Insomnia.
Low-pitched cry.
Positive Babinski reflex.
Bulging fontanel.
The Correct Answer is D
Choice A rationale:
Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.
Choice B rationale:
A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.
Choice C rationale:
A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.
Choice D rationale:
Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.
Choice B rationale:
Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.
Choice C rationale:
This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.
Choice D rationale:
While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.
Correct Answer is C
Explanation
Choice A rationale:
Replacing the ear molds once per year is not a standard recommendation for hearing aid maintenance. The frequency of ear mold replacement may vary depending on individual needs and wear and tear. It is not necessary to replace them annually unless there is a specific issue with the ear molds.
Choice B rationale:
Disinfecting the hearing aid with isopropyl alcohol is not recommended for routine cleaning. Isopropyl alcohol can damage the components of the hearing aid, including the microphone and receiver. Cleaning solutions specifically designed for hearing aids or a soft cloth are safer options for routine cleaning.
Choice C rationale:
Cleaning the hearing aid with a soft cloth is the correct action to take when caring for hearing aids. Routine cleaning with a soft cloth helps remove dust, debris, and earwax from the hearing aid's surface without causing damage to the components. It is a safe and effective method of maintaining hearing aid hygiene.
Choice D rationale:
Changing the battery once per month is not a fixed rule for all hearing aids. The frequency of battery replacement depends on the type of hearing aid, battery size, and individual usage patterns. Some batteries may last longer than a month, while others may need replacement sooner. Clients should be instructed to replace the battery when it no longer functions effectively.
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