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. Preschool children experience fear related to the disease process. While preschool children may fear pain or separation, this statement does not directly address their perception of death.
B. Preschool children understand death completely. Preschool children do not fully understand the permanence of death; this comprehension develops later.
C. Preschool children have no concept of death. Preschoolers have some concept of death but often see it as temporary or reversible.
D. Preschool children perceive death as temporary. Preschool-aged children often view death as temporary, like sleeping, due to their limited understanding of its finality.