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 B
Explanation
The regulation of acid-base balance in the body involves multiple systems working together. The respiratory system, renal system, and chemical-buffering systems play key roles in maintaining the balance of acids and bases in the body.
The respiratory system helps regulate acid-base balance through the control of carbon dioxide (CO2) levels in the blood. By adjusting the rate and depth of breathing, the respiratory system can increase or decrease the elimination of CO2, which affects the pH of the blood.
The renal system (kidneys) plays a crucial role in regulating acid-base balance by controlling the excretion and reabsorption of hydrogen ions (H+) and bicarbonate ions (HCO3-) in the urine. The kidneys can excrete excess acids or bases to help maintain the body's pH within a normal range.
The chemical-buffering systems involve various chemical compounds in the body that can absorb or release hydrogen ions to help maintain pH balance. Examples of chemical buffers include bicarbonate ions (HCO3-), phosphate ions (HPO4-), and proteins.
the cardiovascular and integumentary systemin (option A) is incorrect because they, are not primarily responsible for regulating acid-base balance in the body.
Correct Answer is A
Explanation
The statement that accurately describes the difference between the central nervous system (CNS) of a child and an adult is option A. The brain of a term infant weighs less than half of the weight of the adult brain. The brain undergoes significant growth and development during childhood and continues to develop until early adulthood. At birth, the brain is only a fraction of its adult weight, and it continues to grow and mature over time.
infant has 150 mL of cerebrospinal fluid (CSF) compared with 50 mL in the adult in (option B), is incorrect. The volume of CSF in the CNS is not a significant difference between children and adults.
coordination and fine motor skills develop as myelination of peripheral nerves progresses in (option C), is an incorrect statement. Myelination is an ongoing process that occurs throughout childhood and contributes to the development of coordination and fine motor skills.
papilledema is a common manifestation of increased intracranial pressure (ICP) in the very young child in (option D), is not correct. Papilledema refers to swelling of the optic disc and is not commonly seen in very young children. Signs of increased ICP in young children may present differently compared to adults and can include altered mental status, irritability, vomiting, and changes in vital signs.
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