When observing an infant for symptoms of increased intracranial pressure, the earliest symptom would be detected by measurement of
a. urine output c. blood pressure
b. head circumference d. respirations
B
Head circumference, bulging fontanels, and separated sutures are the earliest signs of increased intracranial pressure in the neonate. Decreased urinary output, hypertension, and unstable respirations are late indicators.
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The respirations of a patient who is demonstrating pursed-lip breathing, flared nostrils, and retractions are described as:
a. tachypnea. b. stertorous. c. dyspnea. d. Cheyne-Stokes.
A nurse is designing a home care plan for a child with a congenital disease and is assessing the family values regarding home care. What is the best resource for the nurse to use?
a. Current literature on congenital deformi-ties b. General knowledge of the culture c. Patient's family d. Written survey
You roll a cotton swab saturated with a patient's penile discharge over a Thayer-Martin plate for a culture in what type of pattern?
a. in a circular pattern from the center of the plate outward b. from side to side to cover as much of the surface as possible c. C pattern d. Z pattern
Severe shock results when the client has lost more than what percentage of the circulating blood volume?
a. less than 20% c. 5% b. between 20 and 40% d. more than 40%