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 ["A","B","C"]

Explanation

A. Manifestations that could indicate a sepsis infection should be monitored closely as bacterial meningitis can lead to septicemia. Signs such as low blood pressure, rapid heart rate, and poor perfusion need immediate attention.

B. Long-term effects that result from a prolonged recovery should be considered. Children recovering from bacterial meningitis may develop complications such as hearing loss, cognitive delays, or motor impairments, requiring long-term follow-up.

C. Blood pressure that could indicate hypertension should be monitored, as increased intracranial pressure (ICP) from meningitis may lead to systemic hypertension, an important parameter to manage during acute illness.

D. Heart problems that result from cardiac dysfunction are not commonly associated with bacterial meningitis itself. However, indirect complications such as septic shock could affect cardiac function, although this is less direct.

E. A decrease in body temperature as a sign of bacterial meningitis progression is incorrect. Hypothermia is not typically a sign of meningitis progression. Fever is a more common manifestation of bacterial meningitis and should be monitored instead.

A. The nurse monitors the child's vital signs every 2 to 4 hours B. The nurse carefully washes his/her hands before and after providing care C. The child has been placed in a semi-private room D. The nurse assesses the child for clinical signs of an infection

Correct Answer is C

Explanation

A. The nurse monitors the child's vital signs every 2 to 4 hours is appropriate. Regular monitoring of vital signs is important in children with neutropenia to detect early signs of infection or sepsis.

B. The nurse carefully washes his/her hands before and after providing care is appropriate. Hand hygiene is critical in preventing the transmission of infection, especially in neutropenic patients who are at high risk of infections.

C. The child has been placed in a semi-private room requires further education. A child with a neutrophil count of 225 is at significant risk of infection, and placing the child in a semi-private room increases the risk of exposure to pathogens. The child should be placed in a private room to minimize exposure to infectious agents.

D. The nurse assesses the child for clinical signs of an infection is appropriate. Vigilant monitoring for infection is essential in neutropenic patients, as they are more susceptible to infections.

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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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Naxlex Comprehensive Predictor Exams

. A nurse is caring for a child who has been diagnosed with bacterial meningitis. Which of the following should the nurse monitor in the child? (Select All that Apply.)

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

Explanation

A child has been admitted to the pediatric unit. Her absolute neutrophil count is 225 and the child has been placed in neutropenic isolation. Which action by a nurse indicates that the nurse requires further education? (Select all that apply)

Correct Answer is C

Explanation

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