A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect?
Depressed scalp veins
Sunken anterior fontanels
Bulging eyes
Separated cranial sutures
The Correct Answer is D
A. Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.
B. Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.
C. Bulging eyes: In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur. The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.
D. Separated cranial sutures: The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Droplet:
Pertussis is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve placing the child in a private room or with another child with the same infection. Healthcare workers should wear a mask or respirator when entering the room to protect against droplet transmission.
B. Contact:
Contact precautions are used for infections that can be spread by direct or indirect contact with the patient or their environment. Pertussis is not typically spread through contact with contaminated surfaces or objects.
C. Airborne:
Airborne precautions are used for infections that are transmitted through small droplet nuclei that remain in the air for long periods. Pertussis is primarily transmitted through larger respiratory droplets rather than tiny airborne particles.
D. Protective environment:
Protective environment precautions are used for patients who have weakened immune systems, such as those undergoing bone marrow transplants. These precautions are not applicable for a child with pertussis.
Correct Answer is ["C","E"]
Explanation
A. "Hyperextend your child's head for 5 minutes following a seizure."
This instruction is incorrect. Hyperextending the head after a seizure is not recommended and could potentially cause harm. Instead, it's important to ensure that the child's airway is clear and maintain a safe and comfortable position.
B. "Immediately following a seizure, give your child 6 ounces of water."
This instruction is not necessary unless the child specifically requests water or appears to be dehydrated. It's important to focus on ensuring the child's safety and comfort immediately after a seizure.
C. "Following a seizure, record the length and characteristics of your child's seizure."
This instruction is correct. Keeping a record of the length and characteristics of the child's seizures can provide valuable information to healthcare providers for managing the child's epilepsy and adjusting treatment as needed.
D. "Administer rectal diazepam to your child following a seizure."
This instruction may be appropriate in some cases, particularly if the child's seizures are prolonged or if they have a history of status epilepticus. However, the administration of rectal diazepam should be done according to the healthcare provider's instructions and with proper training.
E. "Call for emergency medical services if the size of your child's pupils are unequal after a seizure."
This instruction is correct. Unequal pupil size (anisocoria) after a seizure could indicate a serious underlying condition and should prompt immediate medical evaluation. It's important for the parents to be aware of this potential sign of concern and to seek prompt medical attention if it occurs.
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