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:
Establish learning outcomes. Establishing learning outcomes is an important step in developing an education program, but it should not be the first step. Before setting learning outcomes, the nurse should assess the participants' needs and abilities, which includes determining their literacy level. Without this information, it is difficult to create meaningful and relevant learning outcomes.
Choice B rationale:
Create handouts for participants. Creating handouts is an essential part of the education program, but it should come after determining the literacy level of participants. Handouts should be tailored to the participants' literacy levels to ensure that they can understand and benefit from the materials provided.
Choice D rationale:
Schedule a time to implement the program. Scheduling a time to implement the program is also an important step, but it should not be the first action taken. Before scheduling, the nurse needs to gather information about the participants' needs and abilities to ensure that the program is appropriately designed and timed for their convenience.
Choice C rationale:
Determine the literacy level of participants. Determining the literacy level of participants should be the first action taken when developing an education program for older adults. This step is crucial because it helps the nurse understand the participants' reading and comprehension abilities. It allows the nurse to tailor the program materials and teaching methods to match the literacy level of the group. Older adults may have varying levels of literacy, and customizing the program to their needs will improve its effectiveness and ensure that participants can fully engage and benefit from the educational content.
Correct Answer is A
Explanation
Choice A rationale:
"I will notify my doctor if the stoma starts to look purple" indicates an understanding of the importance of monitoring the colostomy site for signs of compromised blood flow or ischemia. A purple or bluish color of the stoma may suggest reduced blood supply, which is a critical concern and should be reported promptly to the healthcare provider.
Choice B rationale:
"I should expect my stool to be formed" is incorrect. In a colostomy, the type of stool output will depend on the location of the colostomy and the surgical procedure performed. Stool consistency can vary, and it may be formed or semi-formed depending on the individual and the specific situation. Expecting formed stool may not always be accurate.
Choice C rationale:
"I will no longer be able to eat nuts" is not necessarily true for all individuals with a colostomy. While some people may experience digestive difficulties with certain foods, including nuts, it is not a universal rule. Dietary restrictions should be discussed with a healthcare provider or a registered dietitian based on the individual's specific condition and needs.
Choice D rationale:
"I will irrigate the colostomy every day" is not a recommended practice for all colostomy patients. Colostomy irrigation is a procedure that may be performed by some individuals with descending or sigmoid colostomies to regulate bowel movements. However, it is not necessary or appropriate for all colostomy patients. The need for colostomy irrigation should be determined by the healthcare provider and discussed with the patient as part of their individualized care plan.
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