The nurse is preparing to admit a 6-month-old infant with ...

[imowrer]

The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.)
 
  a. High-pitched cry
  b. Poor feeding
  c. Setting-sun sign
  d. Sunken fontanel
  e. Distended scalp veins
  f. Decreased head circumference

Question 2

The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the nurse plan for this child? (Select all that apply.)
 
  a. Avoid jarring the bed.
  b. Keep the room brightly lit.
  c. Keep the bed in a flat position.
  d. Administer prescribed stool softeners.
  e. Administer a prescribed antiemetic for nausea.

[zenzy]

Answer to Question 1

ANS: A, B, C, E
Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head circumference.

Answer to Question 2

ANS: A, D, E
Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30 degrees.

[imowrer]

Excellent

[6ana001]

TYSM