A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.
Fever greater than 101.5° F (38.6° C).
Decreased urinary output.
Sunsetting eyes.
Bulging anterior fontanel.
Jugular venous distension.
Correct Answer : C,D
A. Fever greater than 101.5° F (38.6° C): Fever may indicate infection, such as meningitis or shunt infection, but it is not a primary sign of increased intracranial pressure (ICP) in infants.
B. Decreased urinary output: Oliguria is not a typical early sign of increased ICP. While it can occur with severe systemic compromise, it is not a direct indicator of ICP changes.
C. Sunsetting eyes: The “sunsetting” sign, where the eyes appear driven downward with the sclera visible above the iris, is a classic indicator of increased ICP in infants due to hydrocephalus and should be closely monitored.
D. Bulging anterior fontanel: A bulging anterior fontanel reflects increased pressure within the cranial vault and is a key early sign of increased ICP in infants.
E. Jugular venous distension: Jugular venous distension is more indicative of cardiac or fluid overload issues rather than increased ICP in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Total volume = 100 mL.
Infusion time = 30 minutes
Infusion time = 30 minutes / 60 minutes/hour
= 0.5 hours.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Correct Answer is ["A","D","F"]
Explanation
Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.
B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.
C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.
D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.
E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.
F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.
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