Which of the following signs is most indicative of hydrocephalus in an infant?
Setting-sun sign.
High-pitched cry.
Sunken fontanel.
Normal head circumference.
The Correct Answer is A
Choice A rationale
The setting-sun sign is a clinical finding where the infant's eyes appear to be driven downward, with the sclera visible above the iris, resembling the sun setting below the horizon. This is highly indicative of hydrocephalus as the increased intracranial pressure (ICP) presses on the midbrain tectum, causing paralysis of upward gaze.
Choice B rationale
A high-pitched, shrill cry is a non-specific sign of neurological distress and is often associated with increased intracranial pressure (ICP). While it can occur with hydrocephalus, it is a less specific and less consistent finding than the setting-sun sign, which directly reflects the mechanical pressure effects on the oculomotor and associated midbrain structures.
Choice C rationale
A sunken or depressed fontanel is a classic sign of dehydration or hypovolemia due to decreased intracranial volume. Conversely, an infant with hydrocephalus, characterized by excessive cerebrospinal fluid accumulation, will typically present with a bulging, tense, and non-pulsatile anterior fontanel due to the severely elevated intracranial pressure.
Choice D rationale
Normal head circumference would be an unexpected finding in an infant with significant, uncompensated hydrocephalus. The defining clinical feature in infants is the rapid and often exaggerated increase in head circumference (macrocephaly), as the cranial sutures are not yet fused, allowing the head to expand markedly to accommodate the accumulating cerebrospinal fluid and rising pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypotonic saline is not the fluid of choice for septic shock because it lowers serum osmolality and can shift fluid into the cells, worsening intravascular volume depletion and hypotension. A 20 mL/kg bolus is the correct volume, but the fluid type and 10 minutes duration are inappropriate for initial resuscitation.
Choice B rationale
The volume of 5 mL/kg is insufficient for the initial resuscitation of a child in septic shock, where the goal is rapid, aggressive replacement of intravascular volume lost due to capillary leak and vasodilation. A 20 mL/kgbolus is the standard. Ringer's lactate is an acceptable crystalloid, but the volume is wrong.
Choice C rationale
𝐃5𝐖 (5.
Choice D rationale
0.9% 𝐍𝐚𝐂𝐥 (𝐧𝐨𝐫𝐦𝐚𝐥 𝐬𝐚𝐥𝐢𝐧𝐞) is an isotonic crystalloid and is the preferred initial fluid choice to expand the intravascular volume rapidly without risk of electrolyte shift. The dose of 20 mL/kgis standard and must be administered rapidly, typically over 5-30 minutes, to correct hypovolemia and improve cardiac output.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Post-ictal confusion, characterized by a period of disorientation, drowsiness, and potential headache, is a universal feature of the post-seizure state following a generalized tonic-clonic event. This transient neurological deficit reflects the exhaustion and metabolic changes within the cerebral cortex after widespread neuronal depolarization.
Choice B rationale
Sudden loss of consciousness occurs at the onset of a generalized tonic-clonic seizure due to the abrupt, widespread, and bilateral electrical discharge throughout the cortex. This loss of awareness defines the generalized nature of the seizure, distinguishing it from focal seizures where consciousness may be preserved.
Choice C rationale
Rhythmic twitching of one extremity while remaining awake and aware describes a focal motor seizure (simple partial), which involves abnormal electrical activity localized to a specific area of one cerebral hemisphere. A generalized tonic-clonic seizure involves both hemispheres and global loss of consciousness.
Choice D rationale
Urinary incontinence is common during the tonic phase of the seizure due to the intense, generalized muscular contraction, including the pelvic floor muscles. The massive autonomic surge and muscular rigidity overwhelm the sphincter control, leading to involuntary voiding.
Choice E rationale
Rhythmic muscle twitching, known as the clonic phase, consists of alternating periods of muscular contraction and relaxation. This phase follows the rigid, sustained contraction of the tonic phase and is a defining characteristic of a generalized tonic-clonic seizure.
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