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 D
Explanation
A. "Get the child tested for Reye's syndrome if the child exhibits fever, vomiting, and lethargy.": While these are symptoms of Reye's syndrome, prevention focuses on avoiding triggers like salicylates during viral illnesses, not merely recognizing symptoms.
B. "Use aspirin instead of acetaminophen for children with viral illness.": Aspirin increases the risk of Reye's syndrome in children with viral illnesses.
C. "Advise parents to have their children immunized against Reye's syndrome.": There is no vaccine for Reye's syndrome; prevention relies on avoiding salicylate use during viral infections.
D. "Avoid giving salicylate-containing medications to a child who has a viral syndrome.": Salicylates, such as aspirin, are the primary risk factor for Reye's syndrome, so avoidance is critical.
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.