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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Lordosis: Lordosis is an excessive inward curvature of the spine, typically seen in the lower back. It is often referred to as "swayback."

B. Torticollis: Torticollis is a condition where the head is tilted to one side and may be rotated to the opposite side. It typically affects the neck muscles and is not related to lateral curvature of the spine.

C. Scoliosis.

Scoliosis is a lateral curvature of the spine. It is characterized by an abnormal sideways curvature of the spine, which can lead to an "S" or "C" shape of the spine. Scoliosis can occur during adolescence, and routine physical examinations may reveal this condition.

D. Kyphosis: Kyphosis is an excessive outward curvature of the spine, which can result in a rounded or hunched back, often seen in the upper back or thoracic spine.

In summary, the lateral curvature of the spine observed in this adolescent should be documented as scoliosis.

A. Positive Western blot test B. CD4-T-cell count 180 cells/mm C. Platelets 150,000/mm D. WBC 5.000/mm³

Correct Answer is B

Explanation

A. Positive Western blot test: A positive Western blot test confirms HIV infection but doesn't provide information about the current immune status or progression of the disease.

B. CD4-T-cell count 180 cells/mm³.

The CD4-T-cell count is a crucial indicator of a person's immune system function, and it's a primary marker used to monitor the progression of HIV infection. A CD4 count of 180 cells/mm³ is significantly below the normal range (which is typically higher), indicating immunosuppression and an increased risk of opportunistic infections. Maintaining and improving immune function is a top priority in the care of clients with HIV.

C. Platelets 150,000/mm³: Platelet counts are important, but they are not the primary indicator for assessing the progression of HIV.

D. WBC 5.000/mm³: The white blood cell count (WBC) is important for assessing overall immune function, but it doesn't provide the same specific information about the immune system status as the CD4-T-cell count.

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The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?

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