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

Answer and Explanation

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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Correct Answer is D

Explanation

A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.

B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.

C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.

D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.

A. Restrain the child's arms. B. Insert a padded tongue blade into the child's mouth. C. Place the child in a side-lying position. D. Elevate the child's legs on a pillow.

Correct Answer is C

Explanation

A. Restrain the child's arms. Restraining the child's arms is unsafe and can cause injury. It is important to allow the seizure to occur without interference, except to ensure the child’s safety.

B. Insert a padded tongue blade into the child's mouth. This is an outdated and incorrect practice. Inserting anything into a seizing child's mouth can cause injury to the mouth or teeth and poses a choking hazard.

C. Place the child in a side-lying position. This is the correct action as it helps maintain an open airway and allows for drainage of saliva or vomit, reducing the risk of aspiration.

D. Elevate the child's legs on a pillow. This is not an appropriate action during a seizure as it does not address the safety and airway management needs of the child. Keeping the child on their side is more important for airway safety.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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