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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Related Questions
Correct Answer is A
Explanation
A. Initiate antibiotic therapy for the child.
This is the priority action. Bacterial meningitis is a medical emergency, and prompt administration of antibiotics is crucial to treat the infection and prevent further complications. Therefore, the nurse should initiate antibiotic therapy as soon as possible after obtaining appropriate cultures.
B. Minimize the child's environmental stimuli.
While reducing environmental stimuli can help decrease the child's discomfort and prevent agitation, it is not the priority action when managing bacterial meningitis. Treating the underlying infection takes precedence to prevent serious complications such as neurological damage or septic shock.
C. Place the child in a side-lying position.
Positioning the child on their side may help prevent aspiration if vomiting occurs, but it is not the priority action in the initial management of bacterial meningitis. The child's positioning can be adjusted as needed once antibiotic therapy has been initiated.
D. Administer pain medication to the child.
Pain management is important for the child's comfort, but it is not the priority action when managing bacterial meningitis. The child's pain may be addressed once antibiotic therapy has been initiated and the child's condition has stabilized.
Correct Answer is D
Explanation
A. Ophthalmologist: This healthcare professional specializes in the diagnosis and treatment of eye disorders. While eye problems can occur in infants, congenital talipes equinovarus specifically involves foot deformities rather than eye issues. Therefore, a referral to an ophthalmologist wouldn't be appropriate for this condition.
B. Nutrition counselor: A nutrition counselor provides guidance on diet and nutrition-related issues. While nutrition is essential for overall health, it's not directly related to the treatment of congenital talipes equinovarus. Therefore, a referral to a nutrition counselor wouldn't typically be part of the care plan for this condition.
C. Speech therapist: Speech therapists, also known as speech-language pathologists, specialize in evaluating and treating communication and swallowing disorders. However, congenital talipes equinovarus doesn't affect speech or swallowing. Therefore, a referral to a speech therapist wouldn't be relevant for this condition.
D. Orthopedic specialist: An orthopedic specialist is a healthcare professional who specializes in the diagnosis and treatment of musculoskeletal conditions, including congenital abnormalities like clubfoot. They are trained to assess the severity of the deformity and develop a treatment plan, which may include non-surgical or surgical interventions to correct the foot alignment. Therefore, a referral to an orthopedic specialist is the most appropriate choice for an infant with congenital talipes equinovarus.
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