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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer an antiemetic before chemotherapy begins is the most appropriate action. Chemotherapy-induced nausea and vomiting can be anticipated, so administering an antiemetic before treatment helps to prevent these symptoms from occurring. This proactive approach is standard practice to manage chemotherapy side effects.
B. Encourage drinking large amounts of favorite fluids may help with hydration, but it doesn't specifically target nausea or vomiting. It’s better to focus on a strategy to directly prevent these symptoms, such as using antiemetics.
C. Offer frequent small meals before and after chemotherapy may help with general appetite and nutrition, but it doesn't directly address nausea and vomiting from chemotherapy.
D. Provide the child's favorite music as a distraction can be helpful for comfort but does not address the underlying issue of chemotherapy-induced nausea and vomiting.
Correct Answer is C
Explanation
A. Notify the adolescent's primary care provider is incorrect. While it is important to notify the healthcare provider, the immediate priority is performing a thorough assessment to determine the severity of the head injury and any potential complications, such as changes in consciousness or neurological status.
B. Collect a detailed past medical history is incorrect. Although collecting medical history is important, it is not the priority in the acute phase of a suspected head injury. The priority is to assess the current condition of the adolescent, especially signs of deterioration.
C. Perform a thorough assessment noting acute conditions is correct. The priority in suspected head injuries is to perform a thorough assessment to evaluate the patient's neurological status. This includes checking for signs of a concussion, increased intracranial pressure, or any other acute conditions that may require immediate intervention.
D. Administer pain medication to the adolescent is incorrect. Pain management is important, but it should not be the first action when a head injury is suspected, as it can mask symptoms or affect the ability to assess neurological function properly.
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