A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP). Which of the following manifestations should the nurse expect?
Insomnia
Positive Babinski reflex
Bulging fontanel
Low-pitched cry
The Correct Answer is C
A. Insomnia: Infants with increased ICP are more likely to be lethargic than to have insomnia.
B. Positive Babinski reflex: A positive Babinski reflex is normal in infants under 2 years and does not indicate ICP.
C. Bulging fontanel: A bulging fontanel is a classic sign of increased ICP due to the accumulation of fluid or swelling inside the skull.
D. Low-pitched cry: Infants with ICP typically have a high-pitched cry, not a low-pitched one.
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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.
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.