A nurse is evaluating an infant who received treatment for increased intracranial pressure. Which of the following findings should the nurse identify as an indication that the treatment was effective?
Soft, flat fontanels
Increased sleepiness
Enlarged head circumference
Crying when disturbed
The Correct Answer is A
A. Soft, flat fontanels: A soft, flat fontanel indicates that intracranial pressure has decreased and is within normal limits. Elevated pressure often causes bulging or tense fontanels, so this finding suggests effective treatment.
B. Increased sleepiness: Excessive sleepiness or lethargy can indicate worsening or ongoing increased intracranial pressure, so it is not a sign of effective treatment and requires further assessment.
C. Enlarged head circumference: An increasing head circumference in an infant can be a sign of accumulating cerebrospinal fluid or brain swelling, indicating persistent or worsening increased intracranial pressure.
D. Crying when disturbed: While crying is a normal infant behavior, excessive irritability or inconsolable crying may indicate discomfort or increased intracranial pressure rather than improvement. Normal, calm behavior is preferable after treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer glucagon to the vastus lateralis: Glucagon is the treatment of choice for severe hypoglycemia when the child is unable to safely swallow or is experiencing altered mental status. It stimulates glycogen breakdown, rapidly increasing blood glucose.
B. Administer D/W intravenous fluids: Dextrose-containing IV fluids are used to treat hypoglycemia if IV access is available, but glucagon administration is preferred initially if the child is unconscious or unable to take oral glucose safely.
C. Give the child a candy bar: While candy bars provide sugar, they require chewing and swallowing, which may not be safe due to the child's altered mental status and risk of aspiration.
D. Give the child 3 to 6 oz of orange juice: Orange juice is appropriate for mild hypoglycemia when the child is alert and able to swallow safely, but altered mental status indicates a more severe condition needing immediate glucagon or IV glucose.
Correct Answer is C
Explanation
A. Withholding insulin when the child has a poor appetite can lead to hyperglycemia and diabetic ketoacidosis since insulin is still needed during illness even if intake is reduced. Illness typically increases stress hormones, which raise blood glucose levels, making insulin even more necessary.
B. Offering 20 grams of carbohydrates every 2 hours might not be sufficient or appropriate for all children; carbohydrate intake should be balanced with insulin and blood glucose monitoring. Proper carbohydrate intake helps maintain energy and prevent hypoglycemia, especially if the child is eating less than usual.
C. Increasing fluid intake is important during illness to prevent dehydration and help manage blood glucose levels, as illness can cause increased glucose levels and fluid loss. Adequate hydration also supports kidney function and helps flush excess glucose from the bloodstream.
D. Monitoring blood glucose every 8 hours is too infrequent during illness; blood glucose should be checked every 3 to 4 hours to detect and manage hyperglycemia or hypoglycemia promptly. Frequent monitoring allows timely insulin dose adjustments and early intervention.
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