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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Bring your infant into the clinic today to be seen." This is the appropriate response. Projectile vomiting can be a sign of pyloric stenosis, a condition that requires prompt medical evaluation and potential surgical intervention.
B. "You might want to try switching to a different formula." While switching formula might be considered for minor feeding issues, projectile vomiting is severe and warrants immediate medical attention rather than a dietary change.
C. "Give your infant an oral rehydration solution." Oral rehydration might be useful for dehydration, but it does not address the underlying cause of projectile vomiting, which needs to be diagnosed and treated by a healthcare professional.
D. "Burp your child more frequently during feedings." Although burping can help with mild spit-ups, projectile vomiting is a more serious symptom that requires medical evaluation rather than just a change in feeding practices.
Correct Answer is C
Explanation
A. Supine: Lying on the back can limit lung expansion and is not the best position for a child with respiratory issues. It can contribute to atelectasis and does not facilitate effective breathing.
B. Prone: The prone position can improve oxygenation and ventilation, particularly in severe respiratory distress, but it may not be the most comfortable or practical for all patients, especially in a non-ICU setting.
C. Upright: Sitting upright or in a high Fowler's position is optimal for lung expansion. It facilitates easier breathing and helps the lungs expand more fully, allowing for better oxygenation.
D. Side-lying: Side-lying may be comfortable but does not provide as much benefit for lung expansion as the upright position. It is less effective in promoting maximal lung expansion compared to the upright position.
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