A nurse is caring for a newborn who has hydrocephalus.
Which of the following manifestations should the nurse expect to find?
Over-riding suture lines.
A backward sloping appearance of the forehead.
Dilated scalp veins.
Hypertension.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale
Over-riding suture lines are not a typical manifestation of hydrocephalus. This condition involves the accumulation of cerebrospinal fluid within the brain’s ventricles, leading to increased intracranial pressure.
Choice B rationale
A backward sloping appearance of the forehead is not associated with hydrocephalus. This condition typically presents with an enlarged head circumference due to fluid accumulation.
Choice C rationale
Dilated scalp veins are a common manifestation of hydrocephalus. The increased intracranial pressure causes the veins to become more prominent and visible.
Choice D rationale
Hypertension is not a primary symptom of hydrocephalus in newborns. The condition primarily affects the brain and skull, leading to symptoms like an enlarged head, bulging fontanelles, and dilated scalp veins.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
A. Inspection: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B. Auscultation: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C. Superficial palpation: This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D. Deep palpation: This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.
Correct Answer is ["A","C","E"]
Explanation
The correct answers are Choices A, C, and E.
Choice A rationale
Daytime symptoms occurring more than twice a week is an expected finding in mild persistent asthma. This indicates that the asthma is not well-controlled and requires regular use of a controller medication.
Choice B rationale
Nighttime symptoms occurring approximately twice a month is more characteristic of intermittent asthma, not mild persistent asthma.
Choice C rationale
Minor limitations with normal activity are expected in mild persistent asthma. This indicates that the asthma is affecting the child’s daily activities to some extent.
Choice D rationale
Symptoms that are continuous throughout the day are indicative of severe persistent asthma, not mild persistent asthma.
Choice E rationale
A peak expiratory flow (PEF) greater than or equal to 80% of the predicted value is an expected finding in mild persistent asthma. This indicates that the child’s lung function is relatively well-preserved. .
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