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","E","F"]
Explanation
A. Aplastic crisis is caused by a decrease in the production of red blood cells in the bone marrow is correct. Aplastic crisis is often triggered by an infection (such as parvovirus B19), leading to a sudden reduction in red blood cell production, which can exacerbate anemia.
B. Sequestration crisis involves the blockage of small blood vessels by sickled red blood cells is incorrect. This describes a vaso-occlusive crisis, not sequestration crisis. Sequestration crisis involves pooling of blood in the spleen or liver, leading to organ enlargement and circulatory collapse.
C. Vaso-occlusive crisis is characterized by the pooling of large amounts of blood in the spleen and liver is incorrect. Vaso-occlusive crisis is characterized by the blockage of small blood vessels by sickled cells, leading to pain, ischemia, and tissue damage.
D. Aplastic crisis is characterized by the pooling of large amounts of blood in the spleen and liver is incorrect. Aplastic crisis is primarily related to bone marrow failure and reduced red blood cell production, not blood pooling in organs.
E. Sequestration crisis is characterized by the pooling of large amounts of blood in the spleen and liver is correct. In sequestration crisis, the spleen and liver trap large amounts of blood, which can lead to hypovolemic shock and severe anemia.
F. Vaso-occlusive crisis involves the blockage of small blood vessels by sickled red blood cells is correct. Vaso-occlusive crisis occurs when sickled red blood cells obstruct blood flow in small vessels, causing pain, tissue damage, and potential organ dysfunction.
Correct Answer is B
Explanation
A. The tumor is located in the lower back of the brain in the midline posterior fossa is incorrect. This description is more characteristic of a cerebellar or brainstem tumor, not neuroblastoma.
B. The tumor originated in the adrenal glands is correct. Neuroblastoma typically arises from the adrenal glands, though it can also develop in nerve tissue along the spine, neck, chest, or pelvis.
C. The tumor has not spread to other areas of the child's body is incorrect. Neuroblastoma often metastasizes to other parts of the body, such as the bones, lymph nodes, liver, and skin.
D. The tumor came from malformation of astrocyte glial brain cells is incorrect. This describes gliomas, which are a different category of brain tumors, not neuroblastoma.
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