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
Epispadias is a congenital condition in which the urethral opening is not located at the tip of the penis as is typical but rather along the ventral surface (underside) of the penis. In severe cases, the urethral opening may extend all the way to the bladder.
absence of a urethral opening in (option A) is incorrect because it, describes a condition called urethral agenesis or aplasia, where the urethral opening is completely absent. This is a different condition from epispadias.
a penis shorter than usual for age, in (option B) is incorrect because it is not specific to epispadias and could be caused by various factors unrelated to the condition.
a urethral opening along the dorsal surface (topside) of the penis in (option D) is incorrect because it, is a condition called hypospadias. Hypospadias is another congenital anomaly where the urethral opening is located on the underside or along the ventral surface of the penis, but it is not synonymous with epispadias.
Therefore, epispadias specifically refers to the urethral opening being situated along the ventral surface of the penis.
Correct Answer is A
Explanation
The most appropriate statement by the nurse to a 15-year-old whose friend has mentioned suicide is option A. The statement acknowledges the seriousness of the situation and emphasizes the importance of taking the friend's threat seriously. It also highlights the need for immediate help and intervention. Suicide threats should never be dismissed or taken lightly, and it is crucial to involve professionals who can provide appropriate support and assistance.
"Tell your friend to come to the clinic immediately," in option B is incorrect because places the responsibility solely on the 15-year-old to relay the message to their friend, which may not be the most effective or timely approach.
"If your friend mentions suicide again, get your friend some help," in (option C) is incorrect because it does not address the urgency of the situation. Waiting for the friend to mention suicide again before acting may lead to potential harm.
"You need to gather details about your friend's suicide plan," is incorrect because places the responsibility on the 15-year-old to gather information about the friend's suicidal intentions. While understanding the situation and obtaining relevant details is important, the immediate priority is ensuring the friend's safety and seeking professional help.
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