The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

Alteration in pupil size and reactivity and increased motor response

Extension or flexion posturing and weight gain

Tachycardia and alteration in pupil size and reactivity

Cheyne-Stokes respirations and alteration in pupil size

Answer and Explanation

The Correct Answer is D

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction.

B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP.

C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs.

D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.

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Correct Answer is C

Explanation

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.

B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.

C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.

D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.

A. "We will avoid giving our child any dairy products during an exacerbation." B. "We will make sure our child eats plenty of fruits and vegetables during an exacerbation." C. "We will increase our child's intake of high-fiber foods, such as whole grains and legumes." D. "We will encourage our child to drink plenty of fluids, especially water."

Correct Answer is B

Explanation

A. "We will avoid giving our child any dairy products during an exacerbation." Avoiding dairy products during a Crohn's disease exacerbation is often recommended because many individuals with Crohn's disease are lactose intolerant, and dairy can exacerbate symptoms such as diarrhea.

B. "We will make sure our child eats plenty of fruits and vegetables during an exacerbation." During an exacerbation of Crohn's disease, a high-fiber diet (including many fruits and vegetables) can be problematic, as it may irritate the intestines and worsen symptoms. This statement indicates a need for further teaching.

C. "We will increase our child's intake of high-fiber foods, such as whole grains and legumes." High-fiber foods should generally be avoided during a Crohn's disease flare-up because they can be difficult to digest and may worsen symptoms. However, this advice might be appropriate during periods of remission.

D. "We will encourage our child to drink plenty of fluids, especially water." Hydration is important, particularly during exacerbations, when the risk of dehydration increases due to diarrhea. This is a correct statement.

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The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

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Correct Answer is C

Explanation

The nurse is providing teaching to the parents of a school-aged child newly diagnosed with Crohn's disease about dietary measures to implement during an exacerbation. Which statement made by the parents indicates a need for further instruction?

Correct Answer is B

Explanation

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