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 B
Explanation
The correct answer is choice b. Charge nurse.
Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures
Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue
Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.
Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue
Correct Answer is C
Explanation
Choice A rationale:
Wave hands to attract the attention of law enforcement. Rationale: This is not recommended during an active shooter situation. Waving hands to attract attention may draw the shooter's focus towards you. It's generally safer to stay quiet and hidden rather than trying to signal law enforcement.
Choice B rationale:
Move wounded clients to a safe area before finding shelter. Rationale: While it's important to provide assistance to wounded clients, moving them during an active shooter situation may not be advisable. It can put both the wounded and those attempting to help them at risk. The priority is to find a safe place and take cover while awaiting law enforcement.
Choice C rationale:
Turn cellular phones to silent mode. Rationale: This is the correct action to take. Turning cellular phones to silent mode helps maintain silence and prevent the phone from ringing or vibrating, potentially alerting the shooter to your location. It's essential to maintain silence and avoid drawing attention during an active shooter situation.
Choice D rationale:
Attempt to bargain with the shooter. Rationale: Attempting to bargain with the shooter is not a recommended action. Engaging with the shooter can escalate the situation and put lives at risk. The best course of action is to hide, stay quiet, and await law enforcement intervention.
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