A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
Brisk pupillary reaction to light
Irritability
Tachycardia
Increased sensory response to painful stimuli
The Correct Answer is B
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should bring the infant's favourite blanket to the hospital." Bringing the infant's favourite blanket can provide comfort and a sense of security in an unfamiliar hospital environment. It helps the child feel more at ease and can reduce anxiety and stress associated with hospitalization.
B. "You should begin to manipulate the infant's bedtime based on the hospital’s visiting hours." Disrupting the infant’s usual sleep routine can lead to increased stress and irritability. It is better to maintain familiar routines as much as possible to provide comfort and stability during the hospital stay.
C. "You should read the child a story about hospitalization." At 8 months, an infant may not comprehend stories about hospitalization. Reading stories is more effective for older children who can understand and process the information. The focus for infants should be on comfort and familiarity.
D. "You will need to go home when it is not visiting hours." Parents are typically encouraged to stay with their young children in the hospital whenever possible. Parental presence is crucial for the infant’s emotional well-being and can help reduce anxiety.
Correct Answer is C
Explanation
A. Absent plantar reflexes: This is not typically associated with DDH. DDH affects the hip joint's formation, not reflexes.
B. Inwardly turned foot on the affected side: This finding is more indicative of conditions like clubfoot, not DDH.
C. Asymmetric thigh folds: This is a common finding in DDH. The folds may appear uneven due to the displacement of the femoral head.
D. Lengthened thigh on the affected side: In DDH, the thigh on the affected side may actually appear shorter, not longer, due to hip dislocation.
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