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 C
Explanation
A. "Palliative care focuses on the care of the client." - This statement is accurate. Palliative care is centered around providing comprehensive care that addresses the physical, emotional, social, and spiritual needs of the patient.
B. "Palliative care is an inter-professional approach to the delivery of care." - This statement is also accurate. Palliative care typically involves a team of healthcare professionals, including physicians, nurses, social workers, chaplains, and other specialists, who work collaboratively to provide holistic care.
C. "Palliative care is the same as hospice care." - This statement is incorrect. Palliative care and hospice care share similarities in that they both focus on improving the quality of life for patients with serious illnesses, but they are not the same. The key difference is that palliative care can be provided at any stage of a serious illness, even alongside curative treatments, while hospice care is typically provided when a patient has a terminal illness with a prognosis of six months or less to live.
D. "Palliative care includes symptom management in the cent" - This statement is accurate. Symptom management and relief of distressing symptoms are essential components of palliative care, with the goal of improving the patient's quality of life.
So, the statement in option C is incorrect, and the registered nurse should correct it by explaining the distinction between palliative care and hospice care to the client's family.
Correct Answer is D
Explanation
A.Pyloric stenosis is a condition where there's narrowing of the opening between the stomach and the small intestine. It is not related to inadequate motility of the intestine.
B.Enterocolitis refers to inflammation of the small intestine and colon. While this can cause obstruction in some cases, it's not the primary cause of inadequate motility as seen in the question.
C.Encopresis is the voluntary or involuntary passage of feces outside the toilet in children who should be toilet trained. It is not a cause of mechanical intestinal obstruction.
D. Hirschsprung's disease is a congenital disorder where there is inadequate motility in part of the intestine, leading to mechanical obstruction. It usually affects the colon and is due to the absence of ganglion cells in the affected segment of the bowel.
So, Hirschsprung's disease is the specific condition that leads to inadequate motility and mechanical obstruction of part of the intestine in infants.
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