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 D

Explanation

A. Decreased respiratory rate: AKI typically does not directly affect respiratory rate. Respiratory rate is more closely related to lung function and oxygenation status rather than kidney function.

B. Polyuria: This is an incorrect option. Polyuria, or increased urine output, is not typically seen in acute kidney injury. In fact, oliguria (decreased urine output) or anuria (absence of urine output) are more common in AKI due to decreased kidney function.

C. Hyperactivity: AKI does not typically cause hyperactivity. In fact, children with AKI may appear lethargic or fatigued due to the buildup of waste products in their bodies and electrolyte imbalances.

D. Edema: This is the correct option. Edema, or swelling due to fluid retention, is a common clinical manifestation of AKI. When the kidneys are unable to adequately filter and excrete excess fluid from the body, fluid accumulates in the tissues, leading to edema. Edema may be particularly noticeable in the face, hands, feet, or around the eyes.

A. An adolescent who has iron-deficiency anemia and an Hgb level of 11 g/dL (10 to 15.5 g/dL) B. A school-age child who has diabetes mellitus and an HbA1c of 8% (less than 7%) C. A toddler who has moderate dehydration and an RBC count of 5.6/mm3 (4 to 5.5/mm3) D. A preschooler who has cystic fibrosis-related diabetes and a WBC count of 15,000/mm3 (5,000 to 10,000/mm3)

Correct Answer is D

Explanation

A. An adolescent who has iron-deficiency anemia and an Hgb level of 11 g/dL (10 to 15.5 g/dL):

An Hgb level of 11 g/dL in an adolescent with iron-deficiency anemia is within the expected range for someone with this condition. While iron-deficiency anemia requires management, it is not an urgent or critical condition requiring immediate intervention.

B. A school-age child who has diabetes mellitus and an HbA1c of 8% (less than 7%):

An HbA1c level of 8% in a child with diabetes mellitus indicates poor glycemic control and may increase the risk of long-term complications. While it requires attention and adjustment of the treatment plan, it is not an urgent or critical condition requiring immediate intervention.

C. A toddler who has moderate dehydration and an RBC count of 5.6/mm3 (4 to 5.5/mm3):

Moderate dehydration in a toddler is a concerning finding that requires prompt intervention to restore fluid balance and prevent complications. However, the RBC count of 5.6/mm3 is within the normal range and does not indicate an urgent or critical condition.

D. A preschooler who has cystic fibrosis-related diabetes and a WBC count of 15,000/mm3 (5,000 to 10,000/mm3):

A WBC count of 15,000/mm3 in a preschooler with cystic fibrosis-related diabetes may indicate an infection or inflammatory process. Elevated WBC count warrants further assessment and possible intervention to identify and treat the underlying cause, making this the priority.

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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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