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 B
Explanation
Choice A rationale:
Severe nausea and vomiting are not typically associated with an ectopic pregnancy at 8 weeks of gestation. Instead, nausea and vomiting are common symptoms of a normal intrauterine pregnancy due to hormonal changes. Ectopic pregnancies often present with different symptoms, such as pelvic pain and vaginal bleeding.
Choice B rationale:
Pelvic pain is a common and concerning symptom of an ectopic pregnancy. It occurs because the fertilized egg implants outside the uterus, usually in the fallopian tube, which can lead to pain and discomfort as the pregnancy progresses.
Choice C rationale:
Uterine enlargement greater than expected for gestational age is not a typical finding in an ectopic pregnancy. In an ectopic pregnancy, the fertilized egg implants outside the uterus, so uterine enlargement is usually not evident or is less than expected for the gestational age.
Choice D rationale:
Copious vaginal bleeding is a possible but not specific finding in an ectopic pregnancy. While vaginal bleeding can occur, it is often not as heavy as the bleeding associated with a miscarriage or a normal intrauterine pregnancy. Pelvic pain is usually the more prominent symptom.
Correct Answer is A
Explanation
Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.
Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.
Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.
Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.
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