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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D"]

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

A. Plumb line test indicates fetal position curvature. B. Ortolani maneuver causing a click at the hip joint. C. Babinski test that reveals fanning out of toes. D. Moro test precipitating a startle response.

Correct Answer is B

Explanation

A. Plumb line test indicates fetal position curvature: This assessment is used to evaluate spinal alignment and posture, not hip integrity. It does not explain asymmetrical buttocks in a newborn.

B. Ortolani maneuver causing a click at the hip joint: A positive Ortolani sign (a “click” or “clunk”) indicates hip dysplasia or subluxation. This finding is significant and should be reported to the healthcare provider for further evaluation and management.

C. Babinski test that reveals fanning out of toes: The Babinski reflex is normal in newborns and does not indicate musculoskeletal abnormality. It is unrelated to asymmetrical buttocks.

D. Moro test precipitating a startle response: The Moro reflex is a normal newborn response and does not indicate hip instability or asymmetry in the buttocks.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is B

Explanation

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