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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You will need to take the entire prescription of antibiotics even if your symptoms improve." Atopic dermatitis is typically not treated with antibiotics unless there is a secondary bacterial infection. The standard treatment usually involves topical corticosteroids and emollients.
B. "The doctor will remove the lesions with liquid nitrogen." This is incorrect as liquid nitrogen is used for treating warts and certain types of skin lesions, not atopic dermatitis.
C. "The doctor might recommend an antihistamine to help control your symptoms." This is a correct statement. Antihistamines can help reduce itching and provide relief, which is a common symptom of atopic dermatitis.
D. "You can relieve your child's discomfort by applying warm compresses to the lesions." Warm compresses are not typically recommended for atopic dermatitis. Cool compresses or baths are more beneficial to reduce itching and inflammation.
Correct Answer is A
Explanation
A. Lime ice pop: A lime ice pop is a good option because it is cold, soothing, and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort. Additionally, it is not acidic or dairy-based, which makes it a safe choice.
B. Cranberry juice: Cranberry juice is acidic, which can irritate the throat and increase discomfort after a tonsillectomy. Acidic foods and drinks should be avoided during the recovery period to prevent irritation and pain.
C. Ice cream: While ice cream is cold and soothing, it contains dairy, which can increase mucus production. This may lead to discomfort and make swallowing more difficult post-surgery. It’s best to avoid dairy products immediately following a tonsillectomy.
D. Hot tea : Hot beverages should be avoided because they can cause vasodilation and increase the risk of postoperative bleeding. Cold or room temperature liquids are preferred to minimize discomfort and prevent complications.
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