Author Question: While working in a public health clinic, the nurse assesses a child who is 3 years old. The nurse ... (Read 94 times)

Metfan725 · **on:** Jun 27, 2018

While working in a public health clinic, the nurse assesses a child who is 3 years old. The nurse finds an open and wide anterior fontanel. The nurse is aware that an open anterior fontanel at this age most likely is:

a. normal c. due to disease, such as rickets
b. a result of prolonged dehydration d. due to a congenital disorder

Question 2

A parent of a child experiencing compartment syndrome asks the nurse to explain what this means. Which of the following is the nurse's best response?

a. This is a serious condition involving increased pressure in sheaths of inelastic fascia leading to massive impairment of circulation.
b. In this condition, the blood has shifted from the circulation to the interstitial spaces, creating a dramatic change in blood pressure.
c. The child is sorting out all experiences into either good or bad and cannot see gray areas.
d. A lot of the blood from the stomach and large muscles has gone to the area of injury to help in healing.

courtney_bruh · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

C

Feedback
A Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not normal.
B Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not the result of prolonged dehydration, but a sunken depressed fontanel points to improper hydration.
C Correct. A wide anterior fontanel in a child older than 2 1/2 years is an abnormal finding. An anterior fontanel that remains open after 2 1/2 years of age may indicate disease such as rickets.
D Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not due to a congenital disorder.

Answer to Question 2

A

Feedback
A Correct. Compartment syndrome is a serious condition involving increased pressure in sheaths of inelastic fascia that support and partition muscles, blood vessels, and nerves. This increased pressure leads to massive impairment of circulation to the muscle encased in that compartment. If not treated immediately, this can lead to muscle death and permanent disability to the extremity.
B Incorrect. This is not a correct explanation of compartment syndrome.
C Incorrect. This is not a correct explanation of compartment syndrome.
D Incorrect. This is not a correct explanation of compartment syndrome.