When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder?
Cerebral palsy
Syndrome of inappropriate antidiuretic hormone (SIADH)
Hydrocephalus
Reye's syndrome
The Correct Answer is C
Hydrocephalus refers to a condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain. In infants, hydrocephalus can cause the head to enlarge rapidly as a result of the increased pressure exerted by the accumulating fluid. This is known as "rapid head growth." The increased intracranial pressure canlead to irritability and poor appetite in infants.
The distended scalp veins are another common sign of hydrocephalus. As the fluid accumulates, it puts pressure on theblood vessels in the brain, causing the veins in the scalp to become more visible and distended.
Cerebral palsy in (option A) is incorrect because is a neurological disorder that affects body movement and musclecoordination, but it does not typically present with rapid head growth or distended scalp veins.
Syndrome of inappropriate antidiuretic hormone (SIADH) in (option B) is incorrect because it is a condition characterized by excessive secretion of antidiuretic hormone, leading to fluid imbalance, but it does not usually cause rapid head growth or distended scalp veins. Reye's syndrome (D) is a rare condition that primarily affects the liver and brain, and it does not typically present with rapid head growth or distended scalp veins.
Therefore, based on the signs described, hydrocephalus (C) is the most likely disorder in this case. It is important to seekmedical attention promptly for a proper diagnosis and appropriate management of hydrocephalus in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hypoglycaemia is characterized by low blood sugar levels. In children, symptoms of hypoglycaemia can vary, but irritability is a common sign. Other signs and symptoms of hypoglycaemia in children may include sweating, trembling, pale skin, hunger, weakness, confusion, and dizziness.
Normal sensorium and serum glucose greater than 160 mg/dL in (Option A) is incorrect because a normal sensorium (normal level of consciousness) and a serum glucose level greater than 160 mg/dL would not be indicative of hypoglycaemia.
Urine positive for ketones and serum glucose greater than 300 mg/dL in (Option B) is incorrect because it describes characteristics of hyperglycaemia (high blood sugar levels) rather than hypoglycaemia. Positive urine ketones and a serum glucose level greater than 300 mg/dL are commonly seen in diabetic ketoacidosis, a complication of high blood sugar levels in diabetes.
Increased urination and serum glucose less than 120 mg/dL in (Option D) is incorrect because it describes increased urination and a serum glucose level less than 120 mg/dL. While a serum glucose level less than 120 mg/dL could indicate hypoglycaemia, increased urination is not a typical sign of hypoglycaemia. Increased urination may be seen in conditions such as diabetes mellitus when blood sugar levels are consistently high.
Correct Answer is C
Explanation
In the given scenario, the 6-year-old patient in skeletal traction is experiencing
pain, edema, and fever. These symptoms raise concerns about the possibility of an infection
at the site of traction. In such cases, the nurse should assess for warmth at the site of pain.
Increased warmth can indicate inflammation, which may be associated with infection. This
assessment finding would require further investigation and intervention, such as notifying the
healthcare provider and obtaining appropriate cultures or imaging studies.
Neurologic status in (Option A) is incorrect because assessing neurologic status, is important
but not the priority in this scenario. Neurologic status assessment is typically performed to
evaluate any neurovascular compromise resulting from the traction, but the presence of pain,
edema, and fever suggests a potential infection that requires immediate attention.
Range of motion of all extremities in (Option B) is incorrect because assessing the range of
motion of all extremities, is not directly relevant to the given symptoms and should not take
priority over assessing for warmth at the site of pain.
Blood pressure in (Option D) is incorrect because assessing blood pressure, is not directly
related to the symptoms of pain, edema, and fever in the context of skeletal traction. While
blood pressure is an essential vital sign, it does not provide specific information about the
potential infection at the site of pain in this situation.
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