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 ["B","D","E"]
Explanation
A. Clear CSF: Clear CSF is typically seen in viral meningitis or normal findings, not bacterial meningitis.
B. Cloudy CSF: Cloudy CSF indicates the presence of infection and is characteristic of bacterial meningitis.
C. Negative gram stain: A negative gram stain indicates the absence of bacterial pathogens, which is not consistent with bacterial meningitis.
D. Decreased glucose content: Bacteria consume glucose, leading to decreased glucose levels in bacterial meningitis.
E. Positive gram stain: A positive gram stain confirms the presence of bacterial organisms in the CSF, supporting a diagnosis of bacterial meningitis.
Correct Answer is B
Explanation
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.