Author Question: What clinical manifestations suggest hydrocephalus in an infant? a. Closed fontanel and ... (Read 109 times)

codyclark · **on:** Jun 28, 2018

What clinical manifestations suggest hydrocephalus in an infant?

a. Closed fontanel and high-pitched cry
b. Bulging fontanel and dilated scalp veins
c. Constant low-pitched cry and restlessness
d. Depressed fontanel and decreased blood pressure

Question 2

33. The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan?

a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
b. Maintain an active, stimulating environment.
c. Perform chest percussion and suctioning every 1 to 2 hours.
d. Perform active range of motion and nontherapeutic touch every 8 hours.

hramirez205 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. A closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, a depressed fontanel, and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

Answer to Question 2

ANS: A
Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.