Author Question: The nurse should expect the anterior fontanel to close at age: a. 2 months c. 6 to 8 months b. 2 ... (Read 42 times)

lindiwe · **on:** Jun 28, 2018

The nurse should expect the anterior fontanel to close at age:

a. 2 months c. 6 to 8 months
b. 2 to 4 months d. 12 to 18 months

Question 2

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to:

a. Refer for immediate medical evaluation.
b. Continue the assessment to determine the cause of neck pain.
c. Ask the parent when the child's neck was injured.
d. Record head lag on the assessment record and continue the assessment of the child.

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

Answer to Question 1

ANS: D
Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation.

Answer to Question 2

ANS: A
These symptoms indicate meningeal irritation and need immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.