A nurse is assessing a five-month-old Infant. The nurse should recognize that which of the following manifestations is associated with a central nervous system (CNS) Infection?
Oliguria
Negative Kernig's sign
Bulging fontanel
Negative Brudzinski sign
The Correct Answer is C
A. Oliguria (decreased urine output) may be a sign of dehydration or kidney dysfunction but is not typically the primary symptom of a CNS infection.
B. A negative Kernig's sign (no resistance to leg extension) is a reassuring sign and suggests that meningitis or other CNS infections are less likely. A positive sign would suggest possible meningitis.
C. Bulging of the fontanel is a sign of increased intracranial pressure, which can occur in CNS infections such as meningitis. This is a critical finding that requires immediate attention.
D. A negative Brudzinski sign means there is no neck stiffness or pain when the neck is flexed, which is a good finding. A positive sign would suggest the presence of meningitis.
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Related Questions
Correct Answer is D
Explanation
A. CPR is not typically necessary unless the child stops breathing or the heart stops during the seizure, which is rare.
B. Restraining a child during a seizure can cause injury. The focus should be on safety and protection, not restraint.
C. Lorazepam may be given if the seizure lasts too long, but ensuring safety is the priority action.
D. The nurse’s priority during a seizure is to ensure the child’s safety by removing hazardous items from the area and ensuring the child does not get injured.
Correct Answer is B
Explanation
A. The temperature of the cast is important to check for heat retention but is not the first priority for infection control.
B. Assessing skin integrity around the cast is a priority to detect signs of infection, irritation, or pressure sores.
C. Range of motion is important but should be assessed once the skin and safety around the cast are ensured.
D. While pain level is important, ensuring skin integrity is a higher priority for preventing complications such as infection.
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