As intracranial pressure increases in the infant who has hydrocephalus, the anterior fontanel becomes tense and bulges, and the eyes appear to be pushed downward. What is this condition called?
a. circumoral cyanosis c. meningitis
b. intussusception d. sunset eyes
D
In hydrocephalus, the balance between the rate of cerebrospinal fluid formation and absorption is disturbed. The infant has an excessively large head at birth, or rapid head growth along with widening cranial sutures. The anterior fontanelle becomes tense and bulges, and the eyes appear to be pushed downward, with the sclera visible above the iris ("sunset eyes"). Increased intracranial pressure causes irritability, restlessness, a high-pitched cry, vomiting, seizures, and a change in level of consciousness. Surgery is necessary. Vital signs, head circumference, and neurological signs must be monitored. Infections must be prevented.
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A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client?
a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information
Which activity best reflects a community health nurse's population focus?
A) Obtaining epidemiologic data about the community B) Developing a program to prevent disease C) Engaging in a caring relationship with groups D) Advocating for increasing resources for a community
The nurse is performing a shift assessment on a patient with aldosteronism. What would the nurse recognize that the kidney's response to this condition would lead to?
A) Anuria B) Oliguria C) Polyuria D) Proteinuria
A newly licensed nurse is assessing a patient who reports constant dull pain over the lower abdomen. The nurse inspects, percusses, palpates, and auscultates the patient's abdomen
After leaving the patient's room, the preceptor says, "Your assessment findings may not be accurate.". What is the rationale for the preceptor's statement? 1. The nurse palpated prior to auscultating. 2. The nurse inspected prior to palpating. 3. The nurse inspected prior to auscultating. 4. The nurse percusses before palpating.