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. Beriberi: Incorrect. Caused by a deficiency in thiamine (Vitamin B1), not linked to high milk consumption.

B. Dehydration: Incorrect. Milk intake can contribute to hydration, though it should not replace water.

C. Diabetes mellitus: Incorrect. High milk consumption is not directly linked to diabetes in toddlers.

D. Iron-deficiency anemia: Correct. Excessive milk can lead to iron-deficiency anemia because milk is low in iron and can interfere with iron absorption from other foods, leading to reduced iron intake.

A. Modeling clay B. Brightly-colored mobile C. 100-piece jigsaw puzzle D. Checkerboard and checkers

Correct Answer is A

Explanation

A. Modeling clay: Correct. This is appropriate for a 4-year-old, helping with fine motor skills and creativity.

B. Brightly-colored mobile: Incorrect. More suitable for infants who are visually stimulated by simple, moving objects.

C. 100-piece jigsaw puzzle: Incorrect. Too complex for a 4-year-old; age-appropriate puzzles typically have fewer pieces.

D. Checkerboard and checkers: Incorrect. This is better suited for older children who understand rules and strategies.

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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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