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 B
Explanation
A. Administer IV antibiotics: While timely antibiotic administration is critical for treating osteomyelitis, obtaining cultures before starting antibiotics ensures accurate identification of the causative organism and appropriate therapy.
B. Obtain a blood culture: Collecting blood cultures first is the priority to identify the infection source and guide targeted antibiotic treatment. This step should precede antibiotic administration whenever possible.
C. Request a referral for physical therapy: Physical therapy is an important part of the long-term management of osteomyelitis to maintain mobility and prevent complications. However, it is not the immediate priority; identifying and treating the infection takes precedence.
D. Record intake and output: Monitoring fluid balance is important for overall care but does not take precedence over identifying the infectious agent and initiating treatment.
Correct Answer is ["A","B","C","D","E"]
Explanation
Rationale for Correct Choices:
- Neurologic improvement is evident as the child is now alert, oriented, interactive, and no longer experiencing headache or positive Brudzinski/Kernig signs. This indicates resolution of meningeal inflammation.
- Hydration and circulation have improved; moist mucous membranes, warm skin, no cyanosis, and capillary refill under 2 seconds show good perfusion and fluid balance.
- Photophobia resolution is seen in the child’s normal pupil response without squinting in room light, suggesting reduced intracranial irritation.
- Vital signs normalization including a temperature of 37° C that has improved from 39 degrees indicating an improvement in the condition and resolution of infection.
Rationale for Incorrect Choice:
- Hypoactive bowel sounds are not a sign of improvement and may indicate slowed gastrointestinal motility or residual effects of illness or immobility.
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