A school nurse is assessing a child who fell from playground equipment and landed head-first. Which of the following manifestations should the nurse recognize as indicating the presence of increased intracranial pressure?
Report of diplopia
Hyperactivity
Nuchal rigidity
Report of sore throat
The Correct Answer is A
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiate an infusion of IV fluids:
Administering IV fluids may be necessary to maintain hydration and support circulation, but it is not the first action to take in managing status asthmaticus. In this acute situation, the priority is to address airway obstruction and respiratory distress.
B. Obtain a blood specimen for ABG analysis:
Obtaining arterial blood gas (ABG) analysis can provide valuable information about the child's respiratory status, including oxygenation and acid-base balance. However, it is not the first action to take in managing status asthmaticus.
C. Administer a dose of an IV corticosteroid:
Administering systemic corticosteroids (such as IV hydrocortisone or methylprednisolone) is a crucial intervention in managing status asthmaticus to reduce airway inflammation and improve respiratory function. However, it is not the first action to take.
D. Apply humidified oxygen:
This is the correct action to take first. Applying humidified oxygen helps improve oxygenation and relieve bronchospasm by providing supplemental oxygen to the child's lungs. Oxygen therapy is essential in managing respiratory distress associated with status asthmaticus and should be initiated promptly.
Correct Answer is D
Explanation
A. Dry mouth: Dry mouth is not a common adverse effect of cefazolin. It is more commonly associated with other medications, such as anticholinergic drugs. While dry mouth may be uncomfortable, it is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
B. Constipation: Constipation is also not a common adverse effect of cefazolin. It is more commonly associated with other medications, dietary factors, or underlying medical conditions. Similar to dry mouth, constipation is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
C. Back pain: Back pain is not a common adverse effect of cefazolin. While musculoskeletal adverse effects can occur with some antibiotics, back pain is not typically associated with cefazolin. However, if severe or persistent back pain occurs, it should be reported to the healthcare provider for evaluation.
D. Urticaria: Urticaria, also known as hives, is a potential adverse effect of cefazolin and other antibiotics. It is characterized by raised, itchy welts on the skin and can be a sign of an allergic reaction. Urticaria should be reported to the healthcare provider immediately, as it may indicate a serious allergic reaction requiring prompt medical attention.
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