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

Explanation

A. This statement is incorrect because processed foods can contain gluten even if they don't have visible flour. Gluten can be found in many processed foods as an additive or stabilizer, such as in sauces, soups, and processed meats. It's important to always check food labels for gluten ingredients.

B. This is correct. Barley and rye are sources of gluten and must be avoided in a gluten-free diet for those with celiac disease.

C. This is correct. Foods like bread, pasta, and cereal commonly contain gluten and need to be avoided by individuals with celiac disease.

D. This is correct. Using separate serving utensils for gluten-free foods helps prevent cross-contamination, which is critical for managing celiac disease.

A. Ribs B. Upper leg C. Head D. Spine

Correct Answer is B

Explanation

A. Ribs are not a typical location for rhabdomyosarcoma, which primarily affects soft tissue. While it can occur in any area of the body, tumors most commonly develop in the muscles, such as in the upper leg.

B. Upper leg is the most common site of rhabdomyosarcoma in children. This cancer originates in the soft tissues, particularly skeletal muscles.

C. Head is a less common site for rhabdomyosarcoma, although it can occur in the head or neck region. However, the upper leg is more frequently affected.

D. Spine is not a typical location for rhabdomyosarcoma. While other sarcomas can affect bones and tissues of the spine, rhabdomyosarcoma generally affects soft tissues like muscles and tendons.

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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

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