The nurse is caring for an infant with a diagnosis of ...

[kshipps]

The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP). The nurse suspects increased ICP if which of the following is noted?
 
  1. Proteinuria
  2. Bradycardia
  3. A drop in blood pressure
  4. A bulging anterior fontanel

Question 2

The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status, which indicates that:
 
  1. The admission was mandated by court order.
  2. The admission was made without the client's consent.
  3. The client has the right to demand and obtain release from the hospital.
  4. The client was committed by a group of designated mental health professionals.

[xoxo123]

Answer to Question 1

4

Rationale: An elevated or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Proteinuria, bradycardia, and a drop in blood pressure are not specific signs of increased ICP. Changes in the level of consciousness and a widened pulse pres-sure are additional signs of increased ICP.

Answer to Question 2

3

Rationale: Generally, voluntary admission is sought by the client or the client's family by written application to the facility. Voluntary clients have the right to demand and obtain release from the hospital. The admission was mandated by court order, the admission was made without the client's consent, and the client was committed by a group of designated mental health pro-fessionals identify the criteria for involuntary or emergency involuntary admission to a mental health care facility.

[kshipps]

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[xoxo123]

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