What notable sign most likely indicates increased intracranial pressure in an infant?

High-pitched cry.

Decreased lower extremity movement.

Excessive wet diapers.

Bulging fontanel when crying.

Answer and Explanation

The Correct Answer is D

Choice A reason: While a high-pitched cry can be a sign of distress, it is not a specific indicator of increased intracranial pressure.
Choice B reason: Decreased movement in the lower extremities can indicate a neurological issue but is not a specific sign of increased intracranial pressure.
Choice C reason: Excessive wet diapers are not related to intracranial pressure.
Choice D reason: This is the correct choice. A bulging fontanel, especially when crying, can indicate increased intracranial pressure in an infant. It is important to monitor for other signs and symptoms as well.

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Correct Answer is B

Explanation

Choice A reason: IV fluid replacement in DKA is typically isotonic, not hypertonic, to avoid rapid changes in osmolality.
Choice B reason: This is correct. While the total body potassium is depleted in DKA, the initial lab values often show hyperkalemia (high potassium) due to the metabolic acidosis, which shifts potassium out of the cells. This can lead to serious cardiac dysrhythmias and even cardiac arrest, making continuous cardiac monitoring and potassium level assessment a top priority.
Choice C reason: Monitoring for hypertension is important, but the primary concern in DKA is managing the acidosis and hyperglycemia.
Choice D reason: This is incorrect. Treatment for DKA involves a continuous IV infusion of regular insulin at a low, steady rate, not high doses of NPH insulin. NPH insulin is an intermediate-acting insulin and is not suitable for the acute management of DKA.

A. "Treatment needs to be started as soon as possible." B. "I realize my infant will require follow-up care until he reaches skeletal maturity." C. "I need to bring my infant to the clinic every 1-2 weeks for new casts." D. "A spica cast will stay in place for 8-10 weeks."

Correct Answer is D

Explanation

Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.

Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.

Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.

Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.

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What notable sign most likely indicates increased intracranial pressure in an infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is of primary importance for a child who is admitted to the PICU for DKA (diabetic ketoacidosis)?

Correct Answer is B

Explanation

Which statement by the parent indicates a need for further teaching regarding clubfoot?

Correct Answer is D

Explanation

A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis?

A nurse is conducting developmental assessments on several children in the day-care setting. Which two children does the nurse identify as having developmental delays?

At which stage of development are children able to understand the permanence of death?

After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?

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When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory-perceptual alterations. This problem is based on which etiology?

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