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 C
Explanation
A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.
B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.
C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.
D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.
Correct Answer is A
Explanation
A. Complete blood count: Zidovudine can cause bone marrow suppression, leading to thrombocytopenia. Pinpoint red spots, or petechiae, are a sign of low platelet count. A CBC is the most relevant test to evaluate for cytopenias and should be reported promptly to the provider.
B. Skin biopsy: A biopsy would help diagnose dermatologic conditions such as rashes, lesions, or malignancies, but petechiae are usually vascular in nature and related to platelet abnormalities.
C. Allergy test: Allergy testing evaluates hypersensitivity to specific allergens but is not relevant here. Petechiae are not typical of allergic reactions; instead, they reflect impaired clotting or low platelets.
D. Electromyography: EMG measures electrical activity in muscles to assess for neuromuscular disorders. It has no connection to the client’s presentation of petechiae and is unrelated to zidovudine’s known adverse effects.
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