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 D

Explanation

A. Laxatives are not typically used for sickle cell crisis unless the client is experiencing constipation, which is unrelated to the crisis itself.

B. Thyroid replacement medications are used for hypothyroidism and would not be a first-line treatment for sickle cell crisis.

C. Diuretics may be used in conditions like heart failure or kidney disease, but they are not indicated for sickle cell crisis and may worsen dehydration.

D. Pain medications are the correct intervention during a sickle cell crisis. The crisis involves severe pain due to the sickling of red blood cells blocking blood flow to tissues. Opioids like morphine and hydromorphone are commonly administered to manage the severe pain.

A. Neurological assessment B. Basic metabolic panel C. Blood pressure/heart rate D. Abdominal assessment E. Complete blood count F. Pain assessment

Correct Answer is ["A","B","C","E","F"]

Explanation

A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.

B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.

C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.

D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.

E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.

F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

Correct Answer is D

Explanation

Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Correct Answer is ["A","B","C","E","F"]

Explanation

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