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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse should avoid manipulating the stent or dressings to prevent dislodging or introducing infection.
B. Tub baths should be avoided until healing occurs, typically after the wound has been sufficiently healed.
C. Fluid restriction is not necessary unless prescribed for another condition.
D. Anticholinergic medications are not indicated unless there is a specific need, such as managing bladder spasms.
Correct Answer is ["B","D","E"]
Explanation
A. Swelling in all extremities is not typically a symptom of VSD; it may indicate a different cardiac or renal issue.
B. Frequent lung infections are common in children with VSD due to pulmonary congestion.
C. Standard weight and growth percentile is not typical for VSD, as the child may experience failure to thrive.
D. Dyspnea occurs due to increased blood flow to the lungs and pulmonary congestion.
E. A heart murmur is a hallmark of VSD, heard due to the abnormal flow of blood through the septal defect.
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