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 D
Explanation
A. A school-age child who cries when the nurse is giving him an injection: Crying during an injection is a normal reaction for a child and does not indicate abuse.
B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruises on the shins are common in toddlers due to normal play and falls. Without other concerning signs, this does not strongly indicate abuse.
C. A preschooler who has a BMI indicating obesity: While childhood obesity can be a sign of neglect in some cases, it is not a specific or immediate indicator of abuse without other signs.
D. An adolescent who asks to stay in the hospital because he likes the room: This is concerning because it might indicate that the adolescent is not feeling safe or comfortable at home, which could be a sign of abuse or neglect.
Correct Answer is D
Explanation
A. Beriberi: Incorrect. Caused by a deficiency in thiamine (Vitamin B1), not linked to high milk consumption.
B. Dehydration: Incorrect. Milk intake can contribute to hydration, though it should not replace water.
C. Diabetes mellitus: Incorrect. High milk consumption is not directly linked to diabetes in toddlers.
D. Iron-deficiency anemia: Correct. Excessive milk can lead to iron-deficiency anemia because milk is low in iron and can interfere with iron absorption from other foods, leading to reduced iron intake.
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