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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Related Questions
Correct Answer is ["6.4"]
Explanation
Convert the child's weight from pounds to kilograms:
Weight in pounds: 30 lb
Conversion: 1 lb ≈ 0.454 kg
Weight in kg: 30 lb× 0.454 kg/lb =13.62 kg
30lb×0.454kg/lb=13.62kg
Calculate the dose in mg:
Dose: 15 mg/kg
15 mg/kg ×13.62kg=204.3 mg
Determine the volume to administer:
Available concentration: 160 mg/5 mL
Volume in mL:
204.3 mg ÷160 mg/5mL
= 204.3mg×5ml ÷160mg
=6.4mL
The nurse should administer 6.4 mL of acetaminophen.
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.
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