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 A
Explanation
Choice A rationale:
Attending a support group to seek help and guidance for handling difficulties indicates the client's acceptance of having a new ileostomy. It demonstrates a proactive approach to coping with the challenges associated with living with an ileostomy.
Choice B rationale:
Having a partner empty the bag for the client to avoid looking at it may indicate avoidance or denial rather than acceptance. While support from a partner is essential, it's also important for the client to actively participate in self-care and adaptation.
Choice C rationale:
Looking forward to having normal bowel movements again may indicate a lack of acceptance or unrealistic expectations since having an ileostomy means a change in bowel function. The client should be educated about the permanence of the ileostomy.
Choice D rationale:
Wishing for a return to the pre-ileostomy sexual relationship may indicate difficulty accepting the changes in body image and function that come with an ileostomy. It may also suggest unrealistic expectations. The client should be encouraged to seek support and counseling for body image issues and sexual concerns.
Correct Answer is A
Explanation
Choice B rationale:
Prothrombin time. Monitoring prothrombin time is not typically required for clients taking levothyroxine. Prothrombin time is a measure of blood clotting and is not directly affected by thyroid hormone replacement therapy.
Choice C rationale:
Blood urea nitrogen. Monitoring blood urea nitrogen is not specifically related to levothyroxine therapy. Blood urea nitrogen is a measure of kidney function and is not typically affected by thyroid hormone replacement.
Choice D rationale:
Serum potassium. Monitoring serum potassium levels is important for some medications, but it is not a primary concern when a client is taking levothyroxine. Levothyroxine is primarily used to replace or supplement thyroid hormones, and its main focus is on thyroid function.
Choice A rationale:
Triiodothyronine. Triiodothyronine (T3) is one of the thyroid hormones, and monitoring its levels is essential when a client is taking levothyroxine. Levothyroxine is a synthetic form of thyroxine (T4), which the body converts into triiodothyronine (T3) Monitoring T3 levels helps ensure that the client's thyroid hormone replacement therapy is effective and that they are not experiencing over- or under-dosage.
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