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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. ``Sweating can occur with hypoglycaemia." Sweating is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system. This statement is accurate and does not require clarification.
B. "My son might have nausea and vomiting with hypoglycemia." Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA), not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating, shakiness, confusion, and hunger. This statement indicates a misunderstanding that needs to be clarified.
C. ``My son might complain of feeling shaky when he has a low blood glucose level." Feeling shaky is a common symptom of hypoglycemia due to the body's response to low blood glucose levels. This statement is correct and does not need clarification.
D. "The onset of low blood glucose usually occurs rapidly." Hypoglycaemia often has a rapid onset, particularly when caused by factors like excessive insulin or missed meals. This statement is accurate and does not require clarification.
Correct Answer is A
Explanation
A. Lime ice pop: A lime ice pop is a good option because it is cold, soothing, and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort. Additionally, it is not acidic or dairy-based, which makes it a safe choice.
B. Cranberry juice: Cranberry juice is acidic, which can irritate the throat and increase discomfort after a tonsillectomy. Acidic foods and drinks should be avoided during the recovery period to prevent irritation and pain.
C. Ice cream: While ice cream is cold and soothing, it contains dairy, which can increase mucus production. This may lead to discomfort and make swallowing more difficult post-surgery. It’s best to avoid dairy products immediately following a tonsillectomy.
D. Hot tea : Hot beverages should be avoided because they can cause vasodilation and increase the risk of postoperative bleeding. Cold or room temperature liquids are preferred to minimize discomfort and prevent complications.
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