A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
Low-pitched cry
Positive Babinski reflex
Insomnia
Bulging fontanel
The Correct Answer is D
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
Correct Answer is A
Explanation
A. "Give her acetaminophen, not aspirin." This is the appropriate response. Acetaminophen is commonly recommended for treating fever in children as it is safer and does not carry the risk of Reye's syndrome, a rare but serious condition associated with aspirin use in children and adolescents, particularly when they have viral infections. This response provides a safe alternative and addresses the immediate concern of fever treatment.
B. "You'll have to call your physician." While consulting a physician is generally good advice, this response does not provide immediate guidance or address the potential risks of giving aspirin to a toddler. It leaves the parent without immediate and necessary information to prevent harm.
C. "Follow the directions on the aspirin bottle for her age and weight." This response is inappropriate and potentially harmful. Aspirin should not be given to children, especially without a physician's guidance, due to the risk of Reye's syndrome. Following dosage directions on an aspirin bottle is unsafe for a toddler, as aspirin is not recommended for children in this age group for fever treatment.
D. "Give her no more than three baby aspirin every 4 hours." This is incorrect and dangerous advice. Giving any amount of aspirin to a toddler is not recommended because of the risk of Reye's syndrome. Suggesting a specific dosage implies that it's safe to give aspirin to a child, which it is not in this context.
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