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 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.
Correct Answer is B
Explanation
A. No venipuncture or blood pressure in left arm is incorrect. This instruction is often associated with patients who have a shunt, a limb with an established intravenous line, or another condition, but it is not specific to Wilms' tumor.
B. Do not palpate abdomen is correct. Wilms' tumor is a type of kidney cancer in children, and the tumor is often palpable in the abdomen. Palpating the abdomen could cause the tumor to rupture, leading to the spread of cancerous cells. To avoid this risk, the abdomen should not be palpated.
C. Collect all urine is incorrect. While urine collection might be necessary for monitoring renal function or assessing signs of metastasis, it is not a standard precaution or warning for a child with Wilms' tumor.
D. Contact precautions is incorrect. Wilms' tumor is not contagious, so contact precautions are not required unless there is a coexisting infectious condition.
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