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 A
Explanation
The nurse's best response to the student nurse regarding why peer relationships become more important during adolescence is option A. Peer relationships become significant during adolescence because they provide adolescents with a sense of belonging. During this developmental stage, adolescents are transitioning from a primary focus on their family to a greater emphasis on peer interactions and social connections. Peer relationships offer a sense of acceptance, support, and identity as adolescents strive to establish their own identities separate from their families.
adolescents dislike their parents in (option B), is not a correct or comprehensive explanation for the increased importance of peer relationships during adolescence. While it is common for parent-child conflicts to arise during this stage, it does not imply that adolescents dislike their parents as a general rule.
suggesting that adolescents no longer need parental control in (option C), is not correct. While adolescents are seeking increased independence and autonomy, they still require parental guidance and support. Parental control and involvement continue to be essential in providing a secure and nurturing environment during adolescence.
They promote a sense of individuality in adolescents in (option D), is incorrect. Peer relationships do contribute to the development of individuality by allowing adolescents to explore their own interests, values, and social roles. However, the primary reason for the increased importance of peer relationships during adolescence is the sense of belonging and social acceptance they provide.
Correct Answer is B
Explanation
The statement that best describes Tanner staging is option B. Tanner staging is a system used
to classify and assess the progression of puberty based on the development of both primary
and secondary sexual characteristics. It provides a framework for evaluating the physical
changes that occur during puberty, such as breast development in females, testicular
enlargement in males, pubic hair growth, and other secondary sexual characteristics. The
Tanner staging system includes several stages that represent the sequential progression of
puberty in individuals.
staging of puberty based on the initiation of primary sexual characteristics in (option A) is not
correct because it, does not encompass the full scope of Tanner staging, as it does not
consider the progression of secondary sexual characteristics.
staging of puberty based on the initiation of menarche (the onset of menstruation) and
nocturnal emissions, in (option C) is not correct. While menarche and nocturnal emissions are
significant events that occur during puberty, they do not encompass the entire Tanner staging
system, which involves a broader range of physical changes.
predictable stages of puberty based on chronologic age, in (option D) is not correct. Tanner
staging is based on the progression of physical changes and sexual maturation, rather than
being solely determined by chronological age. Puberty can vary in onset and duration among
individuals, making chronological age an unreliable indicator of pubertal development.
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