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:
Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.
Choice B rationale:
Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.
Choice C rationale:
Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.
Choice D rationale:
Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.
Correct Answer is C
Explanation
Choice A rationale:
"Provide homeschooling for your child" is not relevant information for the guardians of a child with cystic fibrosis. The primary focus should be on managing the child's medical condition and providing appropriate care rather than discussing education settings.
Choice B rationale:
"Do not include your child when making decisions about treatment" is not appropriate advice. Involving the child in age-appropriate discussions about their treatment and healthcare decisions can empower them and promote their understanding and cooperation with the treatment plan. It is essential to engage children in their care to the extent possible, with guidance from healthcare providers.
Choice C rationale:
"Have your child wear a medical identification wristband" is the correct choice. Children with cystic fibrosis may have specific medical needs or allergies that emergency responders need to be aware of in case of emergencies. A medical identification wristband can provide crucial information about the child's condition and help ensure that they receive appropriate care in emergencies.
Choice D rationale:
"Ensure that your child does not receive the influenza vaccine annually" is not the recommended advice. Children with cystic fibrosis are at higher risk of respiratory infections, and the annual influenza vaccine is generally recommended to help prevent such infections. However, specific medical recommendations may vary, so it's essential for the guardians to follow the guidance of their child's healthcare provider regarding vaccinations.
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