A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?
Oliguria.
Jaundice.
Bulging fontanel.
Negative Brudzinski sign.
The Correct Answer is C
A bulging fontanel is a manifestation associated with a CNS infection in an 11- month-old infant.
A bulging fontanel can be a sign of increased intracranial pressure, which can
occur with meningitis or encephalitis, both of which are types of CNS infections.
Choice A is incorrect because oliguria, or decreased urine output, is not typically associated with a CNS infection.
Choice B is incorrect because jaundice, or yellowing of the skin and eyes, is not typically associated with a CNS infection.
Choice D is incorrect because a negative Brudzinski sign would indicate that there is no neck stiffness, which would be an unlikely finding in a CNS infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When determining that Bryant's traction is appropriately assembled, the nurse should observe that the buttocks is elevated slightly off of the bed.
In Bryant traction, both of the patient’s limbs are suspended in the air vertically at a ninety-degree angle from the hips and knees slightly flexed.
Choice A is incorrect because a padded sling is not used under the knee of the affected leg in Bryant traction.
Choice B is incorrect because skin straps are not used to maintain the leg in an
extended position in Bryant traction.
Choice C is incorrect because weights are not attached to a pin that is inserted into the femur in Bryant traction.
Correct Answer is D
Explanation
a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.
d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
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