UPDATE!!!2025/2026|GUARANTEED
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
*hydrocephalus :A build-up of fluid in the cavities deep within the brain.This causes
increased intracranial pressure. - ANSWER 4
Rationale: An elevated or bulging anterior fontanel indicates an increase in cerebrospinal
fluid collection in the cerebral ventricle.
The nurse is caring for a child who has sustained a head injury in an automobile accident and
is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors
for the earliest sign of increased ICP by assessing for:
1. Apnea
2. Posturing
3. Tachycardia
4. Changes in level of consciousness (LOC) - ANSWER 4
Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of
increased ICP include tachycardia, leading to bradycardia, apnea, systolic hypertension,
widening pulse pressure, and posturing.
1
, The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal
shunt. The nurse includes which of the following instructions?
1. Call the physician if the infant is fussy.
2. Expect an increased urine output from the shunt.
3. Call the physician if the infant has a high-pitched cry.
4. Position the infant on the side of the shunt when the infant is put to bed.
*ventriculoperitoneal shunt:is a surgical procedure that primarily treats a condition called
hydrocephalus. This condition occurs when excess cerebrospinal fluid (CSF) collects in the
brain's ventricles. CSF cushions your brain and protects it from injury inside your skull. -
ANSWER 3
Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will
not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial
area. The result is increased intracranial pressure, which then causes a high-pitched cry in
the infant.
4. The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes
the nursing interventions included in the plan and prepares to monitor for:
1. Signs of hyperglycemia
2. Signs of a bacterial infection
3. The presence of protein in the urine
4. Signs of increased intracranial pressure
*Reye's syndrome: exact cause of Reye's syndrome is unknown, although several factors may
play a role in its development. Reye's syndrome seems to be triggered by using aspirin to
treat a viral illness or infection — particularly flu (influenza) and chickenpox — in children
and teenagers who have an underlying fatty acid oxidation disorder - ANSWER 4
Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's
syndrome.
2
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
*hydrocephalus :A build-up of fluid in the cavities deep within the brain.This causes
increased intracranial pressure. - ANSWER 4
Rationale: An elevated or bulging anterior fontanel indicates an increase in cerebrospinal
fluid collection in the cerebral ventricle.
The nurse is caring for a child who has sustained a head injury in an automobile accident and
is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors
for the earliest sign of increased ICP by assessing for:
1. Apnea
2. Posturing
3. Tachycardia
4. Changes in level of consciousness (LOC) - ANSWER 4
Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of
increased ICP include tachycardia, leading to bradycardia, apnea, systolic hypertension,
widening pulse pressure, and posturing.
1
, The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal
shunt. The nurse includes which of the following instructions?
1. Call the physician if the infant is fussy.
2. Expect an increased urine output from the shunt.
3. Call the physician if the infant has a high-pitched cry.
4. Position the infant on the side of the shunt when the infant is put to bed.
*ventriculoperitoneal shunt:is a surgical procedure that primarily treats a condition called
hydrocephalus. This condition occurs when excess cerebrospinal fluid (CSF) collects in the
brain's ventricles. CSF cushions your brain and protects it from injury inside your skull. -
ANSWER 3
Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will
not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial
area. The result is increased intracranial pressure, which then causes a high-pitched cry in
the infant.
4. The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes
the nursing interventions included in the plan and prepares to monitor for:
1. Signs of hyperglycemia
2. Signs of a bacterial infection
3. The presence of protein in the urine
4. Signs of increased intracranial pressure
*Reye's syndrome: exact cause of Reye's syndrome is unknown, although several factors may
play a role in its development. Reye's syndrome seems to be triggered by using aspirin to
treat a viral illness or infection — particularly flu (influenza) and chickenpox — in children
and teenagers who have an underlying fatty acid oxidation disorder - ANSWER 4
Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's
syndrome.
2
