A nurse is assessing an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

A. Increased appetite: Increased appetite is not associated with increased intracranial pressure in infants. Changes in ICP more commonly affect feeding tolerance negatively, leading to poor feeding, vomiting, or decreased interest in feeding rather than increased intake.

B. Irritability: Irritability is a common early sign of increased intracranial pressure in infants. Rising pressure causes discomfort and headache-like symptoms that infants cannot verbalize, often presenting as persistent crying, restlessness, or difficulty consoling.

C. Flat fontanel: A flat fontanel is considered a normal finding in infants. Increased intracranial pressure is more likely to cause a bulging or tense fontanel due to increased pressure within the skull.

D. Tachycardia: Tachycardia is not a classic sign of increased intracranial pressure. As ICP worsens, infants may develop bradycardia as part of Cushing’s triad, making tachycardia less indicative of elevated ICP.

A. Abdominal assessment: While assessing the abdomen is important in a pediatric admission, there are currently no signs of abdominal distress, vomiting, or pain that are life-threatening. It should be monitored, but it does not require immediate follow-up compared with the other acute findings.

B. Glucose: The child’s glucose level is 90 mg/dL, which falls within normal limits for an 8-year-old. Immediate follow-up is not necessary unless clinical signs suggest hypoglycemia or hyperglycemia.

C. Temperature: The child has a fever of 38.7° C (101.7° F), which, combined with irritability, nuchal rigidity, and recent upper respiratory infection, could indicate a serious infection such as meningitis. Immediate follow-up is warranted to prevent complications and initiate treatment.

D. Pain assessment: The child reports severe headache rated 7/10 and exhibits irritability and lethargy. These neurological symptoms in combination with fever and nuchal rigidity indicate a potential emergent condition and require immediate evaluation.

E. Hemoglobin: Hemoglobin is 9.5 g/dL, which is below normal for an 8-year-old. While this is not immediately life-threatening, it requires prompt attention to determine cause, especially if the child shows fatigue or signs of decreased oxygen delivery.

F. WBC: The WBC count is 14,000/mm³, indicating leukocytosis and possible systemic infection. This finding requires immediate follow-up to guide diagnosis and treatment decisions, particularly in the context of fever and nuchal rigidity.

G. Neurologic assessment: The child is lethargic, irritable, and has nuchal rigidity. These are signs of possible central nervous system involvement, such as meningitis or encephalitis, requiring urgent evaluation.

H. Peripheral pulses: Peripheral pulses are not noted as abnormal, and there is no indication of cardiovascular compromise. Immediate follow-up is not required unless clinical changes occur.