The nurse is assessing an 8-month-old infant for head lag, ...

[olgavictoria]

The nurse is assessing an 8-month-old infant for head lag, pulling the infant by the hands from a supine to a sitting position. The head does not stay in line with the body then being pulled forward.
 
  Which of the following statements best represents the significance of this finding? a. This is a normal finding, as the infant's head will not stay in line until after 8 months of age.
  b. The nurse has not conducted the test correctly and must do it again using proper technique.
  c. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations.
  d. Head lag should not be tested until the child is over 1 year of age.

Question 2

The nurse is working with a child who is experiencing a complication of fractures known as compartment syndrome. Which of the following signs and symptoms is this child most likely to have?
 
  a. headache, dizziness, blurred vision, and sensitivity to the sun
  b. nausea, vomiting, and diarrhea for 2 weeks
  c. a shifting of fluid and electrolytes into the intracellular space
  d. paresthesia, severe pain, and severe swelling of the digits below the affected compartment

[rleezy04]

Answer to Question 1

C

Feedback
A Incorrect. Since the head does not stay in line with the body then being pulled forward into a sitting position, the nurse assesses that this is not normal.
B Incorrect. Pulling the infant by the hands from a supine to a sitting position is the correct means to test for head lag.
C Correct. Significant head lag indicates head control is not keeping pace with normal development, and after 6 months of age may indicate brain injury and should be further investigated.
D Incorrect. Testing for head lag should begin as early as 3 months, no later than 4 months.

Answer to Question 2

D

Feedback
A Incorrect. Headache, dizziness, blurred vision, and sensitivity to the sun are not the signs and symptoms of compartment syndrome.
B Incorrect. Nausea, vomiting, and diarrhea for 2 weeks are not the signs and symptoms of compartment syndrome.
C Incorrect. A shifting of fluid and electrolytes into the intracellular space are not the signs and symptoms of compartment syndrome.
D Correct. The signs and symptoms of compartment syndrome include paresthesia, severe pain, and severe swelling of the digits below the affected compartment.

[olgavictoria]

Correct answers!

[rleezy04]

Great! Please up vote