The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?
A fontanelle that bulges with crying
Increased respiratory rate
A high-pitched cry
Tachycardia
The Correct Answer is A
A. A fontanelle that bulges with crying.
Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.
B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.
C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.
D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Explaining to the teenager that he is lucky to receive good care does not address his emotional and social needs adequately and may minimize his feelings.
B. Arranging for a video conference with his teacher and ensuring schoolwork is available is important but does not address his desire to be with friends or his emotional needs.
C. Asking the child-life specialist to help find activities to distract the teenager can be helpful for providing emotional support but may not address his concerns about being with friends and feeling frustrated.
D. Arrange a multi-disciplinary team meeting, including the teenager and his family, to discuss the situation and set goals together.
In this challenging situation, it's important to involve the patient and their family in decision-making and goal-setting. Advanced osteosarcoma with metastasis to the lungs is a serious and potentially terminal illness. The teenager's feelings and wishes should be respected and taken into consideration. A multi-disciplinary team meeting allows for open communication, including the patient, family, healthcare providers, and specialists, to discuss the situation, the patient's preferences, and the overall care plan.
Correct Answer is D
Explanation
A. Thrombocytopenia: Thrombocytopenia is a condition characterized by a low platelet count, and it is not a typical feature of iron-deficiency anemia.
B. Increased Total Iron-binding Capacity: In iron-deficiency anemia, the Total Iron-binding Capacity (TIBC) is typically increased as the body attempts to compensate for the low iron levels by increasing its capacity to bind and transport iron.
C. Decreased Folate Levels: While iron-deficiency anemia and folate-deficiency anemia are both forms of anemia, decreased folate levels are more characteristic of folate-deficiency anemia, which is a separate condition.
D. Microcytic Red Blood Cells.
Iron-deficiency anemia is characterized by a decrease in the body's iron stores, which in turn affects the production of hemoglobin and red blood cells. This results in the formation of microcytic (smaller than normal) red blood cells. These smaller red blood cells are a typical finding in iron-deficiency anemia.
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