A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP) Which of the following manifestations should the nurse expect?
Insomnia.
Low-pitched cry.
Positive Babinski reflex.
Bulging fontanel.
The Correct Answer is D
Choice A rationale:
Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.
Choice B rationale:
A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.
Choice C rationale:
A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.
Choice D rationale:
Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Provide homeschooling for your child" is not relevant information for the guardians of a child with cystic fibrosis. The primary focus should be on managing the child's medical condition and providing appropriate care rather than discussing education settings.
Choice B rationale:
"Do not include your child when making decisions about treatment" is not appropriate advice. Involving the child in age-appropriate discussions about their treatment and healthcare decisions can empower them and promote their understanding and cooperation with the treatment plan. It is essential to engage children in their care to the extent possible, with guidance from healthcare providers.
Choice C rationale:
"Have your child wear a medical identification wristband" is the correct choice. Children with cystic fibrosis may have specific medical needs or allergies that emergency responders need to be aware of in case of emergencies. A medical identification wristband can provide crucial information about the child's condition and help ensure that they receive appropriate care in emergencies.
Choice D rationale:
"Ensure that your child does not receive the influenza vaccine annually" is not the recommended advice. Children with cystic fibrosis are at higher risk of respiratory infections, and the annual influenza vaccine is generally recommended to help prevent such infections. However, specific medical recommendations may vary, so it's essential for the guardians to follow the guidance of their child's healthcare provider regarding vaccinations.
Correct Answer is B
Explanation
Choice A rationale:
Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.
Choice B rationale:
Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.
Choice C rationale:
Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.
Choice D rationale:
Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.
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