A school nurse is assessing a child who fell from playground equipment and landed head-first. Which of the following manifestations should the nurse recognize as indicating the presence of increased intracranial pressure?
Report of diplopia
Hyperactivity
Nuchal rigidity
Report of sore throat
The Correct Answer is A
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
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Related Questions
Correct Answer is B
Explanation
A. Coarctation of the aorta
Coarctation of the aorta involves a narrowing of the aorta, leading to decreased blood flow to the lower body. It is not associated with increased pulmonary blood flow.
B. Patent ductus arteriosus
Patent ductus arteriosus (PDA) is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that usually closes shortly after birth, remains open. This allows blood to flow from the aorta into the pulmonary artery, increasing pulmonary blood flow. Therefore, option B is correct.
C. Tetralogy of Fallot
Tetralogy of Fallot is a congenital heart defect characterized by four abnormalities, including a ventricular septal defect (VSD), pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. While it can lead to cyanosis due to right-to-left shunting, it is not primarily associated with increased pulmonary blood flow.
D. Tricuspid atresia
Tricuspid atresia involves the absence of the tricuspid valve, leading to a lack of direct blood flow from the right atrium to the right ventricle. It usually presents with decreased pulmonary blood flow rather than increased pulmonary blood flow.
Correct Answer is A
Explanation
A. "Reye syndrome causes fatty changes in the liver."
This statement is correct. Reye syndrome is characterized by acute non-inflammatory encephalopathy and fatty changes in the liver, which can lead to liver dysfunction and failure.
B. "Reye syndrome leads to venous thrombus formation."
This statement is incorrect. Reye syndrome primarily affects the brain and liver, leading to cerebral edema and liver dysfunction. It does not typically involve venous thrombus formation.
C. "Reye syndrome is associated with misuse of acetaminophen."
This statement is incorrect. While the exact cause of Reye syndrome is not fully understood, it is not associated with the misuse of acetaminophen. However, there is a well-established association between Reye syndrome and the use of aspirin (salicylates) during viral infections, particularly in children and adolescents.
D. "Reye syndrome is linked to decreased serum ammonia levels."
This statement is incorrect. Reye syndrome is associated with increased serum ammonia levels due to liver dysfunction and impaired ammonia metabolism. Elevated ammonia levels can contribute to the encephalopathy seen in Reye syndrome.
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