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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Administer packed red blood cells transfusion (PRBC):

While anemia may also be a concern in leukemia, the primary issue here is thrombocytopenia, not anemia. Administering packed red blood cells transfusion would address anemia, not the low platelet count.

B. Avoid taking rectal temperatures:

This is the correct option. Taking rectal temperatures carries the risk of causing bleeding or trauma, especially in individuals with thrombocytopenia. It is essential to avoid invasive procedures or activities that may increase the risk of bleeding in a patient with a low platelet count.

C. Place child in protective environment precautions:

Protective environment precautions, also known as reverse isolation, are typically implemented for patients who are immunocompromised to protect them from exposure to infectious agents. While patients with leukemia may be immunocompromised, the low platelet count is the primary concern here, not infection risk.

D. Swab the oral cavity with viscous lidocaine:

Swabbing the oral cavity with viscous lidocaine is not indicated for thrombocytopenia. Lidocaine may have local anesthetic properties but does not address the underlying issue of low platelet count.

A. "Reye syndrome causes fatty changes in the liver." B. "Reye syndrome leads to venous thrombus formation." C. "Reye syndrome is associated with misuse of acetaminophen." D. "Reye syndrome is linked to decreased serum ammonia levels."

Correct Answer is A

Explanation

A. "Reye syndrome causes fatty changes in the liver."

This statement is correct. Reye syndrome is characterized by acute non-inflammatory encephalopathy and fatty changes in the liver, which can lead to liver dysfunction and failure.

B. "Reye syndrome leads to venous thrombus formation."

This statement is incorrect. Reye syndrome primarily affects the brain and liver, leading to cerebral edema and liver dysfunction. It does not typically involve venous thrombus formation.

C. "Reye syndrome is associated with misuse of acetaminophen."

This statement is incorrect. While the exact cause of Reye syndrome is not fully understood, it is not associated with the misuse of acetaminophen. However, there is a well-established association between Reye syndrome and the use of aspirin (salicylates) during viral infections, particularly in children and adolescents.

D. "Reye syndrome is linked to decreased serum ammonia levels."

This statement is incorrect. Reye syndrome is associated with increased serum ammonia levels due to liver dysfunction and impaired ammonia metabolism. Elevated ammonia levels can contribute to the encephalopathy seen in Reye syndrome.

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A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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