Which of the following is the most concerning sign of increased intracranial pressure in an infant?
High-pitched cry.
Poor feeding.
Separated cranial sutures.
Bradycardia.
The Correct Answer is D
Choice A rationale
A high-pitched cry in an infant can be indicative of increased intracranial pressure (ICP) due to stretching of the meninges or irritation of the central nervous system. However, it is a non-specific sign that may also relate to pain or general distress. Normal infant crying is variable, but this specific quality suggests a potentially serious neurological issue.
Choice B rationale
Poor feeding is a non-specific sign of general illness in an infant, reflecting overall malaise or potentially a depressed level of consciousness secondary to increased ICP. Reduced appetite or difficulty sucking/swallowing suggests decreased neurological function or systemic distress but is often less immediately concerning than vital sign changes.
Choice C rationale
Separated cranial sutures (diastasis) and a bulging fontanelle are classic, late-stage physical findings in infants with chronic or acutely escalating ICP. The unfused sutures provide a compensatory mechanism for the expanding volume, but once separated, it signifies a substantial, long-standing pressure increase.
Choice D rationale
Bradycardia (abnormally slow heart rate) is the most concerning part of the Cushing's Triad (hypertension, bradycardia, and irregular respirations), which is a late and critical physiological response to dangerously elevated ICP. The reduced heart rate is a reflex response mediated by the brainstem to maintain cerebral perfusion pressure (CPP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The constellation of fever (101.5°F or 38.6°C), irritability, and tachycardia (160 bpm, normal for a 2-year-old is ∼80-130 bpm) in a child with a ventricular shunt is highly suggestive of a shunt infection (ventriculitis or meningitis). A shunt infection can lead to septicemia and shunt malfunction, potentially causing rapidly increased intracranial pressure (ICP). Given the high morbidity, this finding requires immediate notification of the provider for prompt diagnostic workup (e.g., shunt tap) and empiric antibiotics.
Choice B rationale
While tachycardia and irritability can sometimes be non-specific symptoms, a fever of 101.5°F is abnormal. The presence of a ventricular shunt significantly raises the index of suspicion for shunt infection, a neurosurgical emergency, which is a life-threatening condition. Documenting and observing without immediate intervention is dangerously negligent given the clinical picture.
Choice C rationale
Administering antipyretics addresses only the fever, a symptom, and does not treat the underlying potentially fatal shunt infection. Delaying notification to reassess in one hour risks rapid neurological deterioration, as shunt infections can progress quickly to sepsis, severe ventriculitis, or uncompensated increased intracranial pressure (ICP). Immediate medical evaluation is the priority.
Choice D rationale
Encouraging oral fluids is a supportive measure for fever and dehydration, but it is not the priority for a child highly suspected of having a ventricular shunt infection. Oral fluid intake can be impaired due to irritability and potential nausea/vomiting associated with increased intracranial pressure, and this action delays definitive diagnosis and treatment of the infection.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Generalized muscle stiffening, or tonic posturing, is characteristic of tonic-clonic seizures, which involve both cerebral hemispheres and typically include a tonic phase of muscle rigidity followed by a clonic phase of rhythmic jerking. This is not a hallmark of focal impaired awareness seizures.
Choice B rationale
Complete loss of consciousness, meaning unresponsiveness to external stimuli, is characteristic of generalized seizures affecting both hemispheres from the onset. Focal impaired awareness seizures involve a change or impairment of consciousness, not necessarily a complete loss, hence the term "impaired awareness.”.
Choice C rationale
A dreamlike state, often described as déjà vu, fear, or a sense of unreality, is a common experiential alteration that can occur during the onset (aura) or ictal phase of a focal impaired awareness seizure, originating typically from the temporal lobe.
Choice D rationale
Sudden, unprovoked emotional outbursts such as fear, anxiety, or laughing (gelastic seizures) are frequently observed manifestations of focal seizures, especially those originating in the limbic system structures like the amygdala within the temporal lobe, reflecting the seizure's impact on emotional processing centers.
Choice E rationale
Automatisms are involuntary, repetitive, non-purposeful behaviors such as lip smacking, chewing, fidgeting, or walking that occur when a person's awareness is impaired during a seizure. They reflect the focal discharge interfering with cortical control over subcortical motor programs.
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