A nurse is assessing a 6-month-old infant who has viral meningitis. Which of the following findings should the nurse expect? (Select all that apply)
Hyperglycemia.
Fever.
Poor feeding.
Difficult to awaken.
Stiff neck.
Correct Answer : B,C,D,E
Choice A reason: Hyperglycemia is not typically associated with viral meningitis. It may occur in metabolic disorders or stress responses but is not a hallmark of meningitis, which primarily affects the central nervous system, causing inflammation, fever, and neurological symptoms rather than blood glucose alterations.
Choice B reason: Fever is a common sign of viral meningitis due to the body’s immune response to viral infection in the meninges. Inflammation triggers pyrogens, elevating body temperature. This systemic response is a key diagnostic indicator in infants, reflecting central nervous system irritation.
Choice C reason: Poor feeding occurs in viral meningitis as infants experience lethargy and irritability from meningeal inflammation. Neurological irritation disrupts normal feeding behaviors, and systemic illness reduces appetite, leading to inadequate intake, a common symptom in infants with central nervous system infections.
Choice D reason: Difficulty awakening is expected in viral meningitis due to meningeal inflammation causing lethargy and altered consciousness. The infection irritates brain structures, reducing arousal responses, making infants less responsive, a critical sign of neurological involvement requiring prompt medical attention.
Choice E reason: Stiff neck, or nuchal rigidity, results from meningeal inflammation in viral meningitis, causing pain and resistance during neck flexion. This occurs as inflamed meninges irritate surrounding nerves, a classic symptom in older children and infants, indicating central nervous system infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Removing the traction boot during baths disrupts Buck extension traction, used to stabilize the femoral head in Legg-Calve-Perthes disease. Continuous traction maintains alignment, and removal risks joint displacement, delaying healing of the avascular necrosis affecting the femoral head.
Choice B reason: Repositioning every 2 hours prevents pressure ulcers and maintains circulation in a child in Buck traction for Legg-Calve-Perthes disease. Regular movement within traction limits reduces skin breakdown and promotes comfort, supporting healing of the femoral head by maintaining proper positioning.
Choice C reason: Antibiotic ointment is used for skeletal traction with pins, not Buck extension traction, which uses skin traction. Legg-Calve-Perthes disease treatment does not involve pins, making this action irrelevant, as there are no pin sites to manage for infection prevention.
Choice D reason: Reducing fluid intake is inappropriate, as adequate hydration supports circulation and healing in Legg-Calve-Perthes disease. Dehydration risks urinary and cardiovascular complications, hindering recovery from avascular necrosis, making this action counterproductive to the child’s overall health and treatment.
Correct Answer is B
Explanation
Choice A reason: Tachycardia is not a primary sign of increased intracranial pressure in infants. It may occur in shock or pain but is less specific than neurological changes like lethargy. Increased intracranial pressure typically causes bradycardia due to brainstem compression, making this incorrect.
Choice B reason: Increased sleeping, or lethargy, indicates increased intracranial pressure in infants, as pressure on brain structures impairs arousal. This neurological symptom reflects cerebral edema or hematoma, reducing consciousness, a critical sign requiring urgent evaluation to prevent brain herniation.
Choice C reason: Depressed fontanels suggest dehydration, not increased intracranial pressure, which causes bulging fontanels in infants due to cerebrospinal fluid or blood accumulation. This finding is opposite to the expected presentation, making it incorrect for monitoring intracranial pressure.
Choice D reason: Brisk pupillary reaction is normal, not indicative of increased intracranial pressure. Sluggish or fixed pupils suggest pressure on cranial nerves, impairing light response. Brisk reactions indicate intact neurological function, making this an incorrect finding for increased intracranial pressure.
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