The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

Alteration in pupil size and reactivity and increased motor response

Extension or flexion posturing and weight gain

Tachycardia and alteration in pupil size and reactivity

Cheyne-Stokes respirations and alteration in pupil size

Answer and Explanation

The Correct Answer is D

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction.

B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP.

C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs.

D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.

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Correct Answer is B

Explanation

A. No venipuncture or blood pressure in left arm is incorrect. This instruction is often associated with patients who have a shunt, a limb with an established intravenous line, or another condition, but it is not specific to Wilms' tumor.
B. Do not palpate abdomen is correct. Wilms' tumor is a type of kidney cancer in children, and the tumor is often palpable in the abdomen. Palpating the abdomen could cause the tumor to rupture, leading to the spread of cancerous cells. To avoid this risk, the abdomen should not be palpated.
C. Collect all urine is incorrect. While urine collection might be necessary for monitoring renal function or assessing signs of metastasis, it is not a standard precaution or warning for a child with Wilms' tumor.
D. Contact precautions is incorrect. Wilms' tumor is not contagious, so contact precautions are not required unless there is a coexisting infectious condition.

A. Has your child had a fever? B. Did your child have an aura prior to a seizure? C. Has your child had two or more seizures, in the last 1 year? D. How long did your child's seizure last?

Correct Answer is B

Explanation

A. Has your child had a fever? While fever can be associated with febrile seizures, it is not a question used to screen for epilepsy. Febrile seizures are typically isolated events in young children and are not considered part of chronic epilepsy.

B. Did your child have an aura prior to a seizure? This is an important question for assessing epilepsy, especially focal seizures, as many individuals with epilepsy experience an aura (a warning sign) before a seizure. The presence or absence of an aura helps in classifying the type of seizure and can be useful in diagnosis.

C. Has your child had two or more seizures, in the last 1 year? This is not a screening question for epilepsy, but it would be relevant if epilepsy has already been diagnosed. Two or more seizures within a year can indicate a seizure disorder, but asking if the child has had multiple seizures would be more appropriate once epilepsy is suspected.

D. How long did your child's seizure last? The duration of a seizure is important to note during an episode, but it is not a question used during initial screening. The nurse would focus more on whether seizures occur, how they manifest, and if there are any warning signs (like an aura) prior to the event.

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The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

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Naxlex Comprehensive Predictor Exams

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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