A nurse is collecting data from a 4-month old infant who has meningitis. Which of the following findings should the nurse expect?
Depressed anterior fontanel
High Pitched cry
Constipation
Presence of the rooting reflex
The Correct Answer is B
A. Depressed anterior fontanel: A depressed fontanel is typically associated with dehydration, not meningitis.
B. High-pitched cry: A high-pitched cry is a classic symptom of meningitis in infants, often associated with increased ICP.
C. Constipation: Meningitis is more likely to cause irritability and feeding difficulties than constipation.
D. Presence of the rooting reflex: The rooting reflex is normal in a 4-month-old and does not specifically indicate meningitis.
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Correct Answer is A
Explanation
A. "I should place a cool mist humidifier in his room.": Children with Down Syndrome often have narrow nasal passages and a tendency toward respiratory infections. A cool mist humidifier helps keep the airways moist, reducing irritation and easing breathing.
B. "I should expect him to have frequent diarrhea.": Diarrhea is not a common symptom associated with Down Syndrome; constipation is more frequent due to low muscle tone.
C. "I should expect him to grow faster in length than other infants.": Infants with Down Syndrome tend to have slower growth rates and may not reach the same length or weight milestones as peers.
D. "I should avoid the use of lotion on his skin.": Infants with Down Syndrome often have dry, sensitive skin, and the use of lotion is encouraged to prevent dryness and cracking.
Correct Answer is C
Explanation
A. Reduce environmental stimuli: While minimizing stimuli is important for comfort, it is not the priority in treating a life-threatening bacterial infection.
B. Document intake and output: Monitoring fluid status is essential but secondary to administering life-saving treatment.
C. Administer antibiotics when available: Bacterial meningitis is a medical emergency. Administering antibiotics promptly can reduce mortality and prevent complications such as neurological damage.
D. Maintain seizure precautions: Seizure precautions are necessary but do not take precedence over starting antibiotics.