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

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place a warm, moist heat pack on the cast: Incorrect. Moisture can damage the integrity of a plaster cast, and heat can increase swelling.

B. Position the casted arm in a dependent position: Incorrect. Keeping the arm elevated helps reduce swelling and pain.

C. Move the casted arm with a firm grasp: Incorrect. A firm grasp can cause further injury or discomfort. It’s important to handle the casted limb gently.

D. Administer diphenhydramine to relieve itching: Correct. Itching is common under a new cast, and diphenhydramine can help manage this symptom without risking damage to the cast.

Correct Answer is ["7"]

Explanation

Formula: Volumetoadminister=Desireddose/Availabledose ×Volumeavailable

Calculation: 350mg/250mg × 5mL=7mL

Answer: 7 mL

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to administer amoxicillin 350 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["7"]

Explanation

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