A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
Brisk pupillary reaction to light
Irritability
Tachycardia
Increased sensory response to painful stimuli
The Correct Answer is B
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
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Related Questions
Correct Answer is D
Explanation
A. Keep the client's leg in a dependent position. Keeping the leg in a dependent position can increase swelling and delay healing. The leg should be elevated to reduce swelling and promote circulation.
B. Use a hair dryer on a hot setting to dry the cast. Using a hair dryer on a hot setting can cause burns and does not effectively dry a plaster cast. Plaster casts take time to dry and should be air-dried naturally.
C. Discourage the client from ambulating: Early mobilization is encouraged to prevent complications like muscle atrophy and joint stiffness, as long as it is safe and the healthcare provider has approved it. Completely discouraging ambulation is not generally recommended unless specified by a doctor.
D. Perform a neurovascular check of the lower extremities. Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast. This includes checking for pain, pallor, pulse, paresthesia, and paralysis (the 5 P’s). This helps detect complications like compartment syndrome or decreased circulation early.
Correct Answer is B
Explanation
A. Decreased hematocrit: Hematocrit usually increases in dehydration due to the concentration of red blood cells in a smaller volume of plasma.
B. Increased respiratory rate: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume and maintain oxygen delivery.
C. Decreased heart rate: Dehydration typically causes tachycardia (increased heart rate) as the body tries to maintain adequate blood circulation and pressure.
D. Increased platelet count: Dehydration does not typically affect platelet count significantly, though it may concentrate blood components, including platelets, making them appear elevated on a lab test.
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