A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?

A. Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.

B. Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor. Other symptoms should take precedence.

C. Pruritus (itching) is a common symptom that can have various causes, and it may not be directly related to the brain tumor. It should be addressed but is not the priority in this case.

D. Correct. Diplopia (double vision) can be a neurological symptom associated with increased

intracranial pressure or other complications related to a brain tumor. It is important to report this finding promptly to the provider for further evaluation and intervention.

A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.

B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.

C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.

D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.