Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 3-month-old neonate is admitted with suspected hydrocephalus. Upon assessment, which clinical manifestation should the nurse prioritize as indicative of increased intracranial pressure?
A. Closed fontanel and high-pitched cry
Closed fontanel and high-pitched cry is incorrect because a closed fontanel is normal at this age only if ossification is occurring, and a high-pitched cry may indicate pain or neurologic irritation but is not the most specific sign of increased ICP.
B. Bulging fontanel and dilated scalp veins
Bulging fontanel and dilated scalp veins is correct because increased intracranial pressure (ICP) in infants often presents with a bulging, tense fontanel due to accumulation of cerebrospinal fluid, and prominent scalp veins result from increased venous pressure. These are hallmark early signs of hydrocephalus and warrant prompt attention.
C. Constant low-pitched cry and restlessness
Constant low-pitched cry and restlessness is incorrect because while irritability and restlessness may accompany increased ICP, a low-pitched cry is not a classic indicator, and these signs are nonspecific.
D. Depressed fontanel and decreased blood pressure
Depressed fontanel and decreased blood pressure is incorrect because a depressed fontanel usually indicates dehydration, not increased ICP, and hypotension is a late and less reliable sign of increased ICP in infants.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. Closed fontanel and high-pitched cry is incorrect because a closed fontanel is normal at this age only if ossification is occurring, and a high-pitched cry may indicate pain or neurologic irritation but is not the most specific sign of increased ICP.
B. Bulging fontanel and dilated scalp veins is correct because increased intracranial pressure (ICP) in infants often presents with a bulging, tense fontanel due to accumulation of cerebrospinal fluid, and prominent scalp veins result from increased venous pressure. These are hallmark early signs of hydrocephalus and warrant prompt attention.
C. Constant low-pitched cry and restlessness is incorrect because while irritability and restlessness may accompany increased ICP, a low-pitched cry is not a classic indicator, and these signs are nonspecific.
D. Depressed fontanel and decreased blood pressure is incorrect because a depressed fontanel usually indicates dehydration, not increased ICP, and hypotension is a late and less reliable sign of increased ICP in infants.
Similar Questions
A 10-year-old child with a distal femoral fracture involving the growth plate is admitted for treatment. Which nursing action should be prioritized to prevent long-term complications related to growth disturbances?
A. instruct the child to avoid weight-bearing activities indefinitely to prevent fracture displacement.
Instruct the child to avoid weight-bearing activities indefinitely is incorrect because prolonged immobilization is unnecessary and can lead to muscle atrophy and delayed functional recovery. Weight-bearing should be restricted only as medically indicated during the initial healing phase.
B. Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb.
Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb is incorrect because growth plate (physeal) fractures can lead to limb length discrepancies or angular deformities if not properly monitored. Providing false reassurance could delay necessary interventions.
C. Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement.
Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement is incorrect because pediatric fractures involving the growth plate may have unique healing patterns and potential complications, including growth disturbances.
D. Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies.
Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies is correct because distal femoral physeal fractures carry a high risk for growth disturbances, including limb shortening or angular deformities. Regular follow-up with imaging and growth monitoring allows early identification and intervention, minimizing long-term functional and cosmetic complications.
Full Explanation
A. Instruct the child to avoid weight-bearing activities indefinitely is incorrect because prolonged immobilization is unnecessary and can lead to muscle atrophy and delayed functional recovery. Weight-bearing should be restricted only as medically indicated during the initial healing phase.
B. Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb is incorrect because growth plate (physeal) fractures can lead to limb length discrepancies or angular deformities if not properly monitored. Providing false reassurance could delay necessary interventions.
C. Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement is incorrect because pediatric fractures involving the growth plate may have unique healing patterns and potential complications, including growth disturbances.
D. Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies is correct because distal femoral physeal fractures carry a high risk for growth disturbances, including limb shortening or angular deformities. Regular follow-up with imaging and growth monitoring allows early identification and intervention, minimizing long-term functional and cosmetic complications.
A nurse is assessing the sexual maturity of a 14-year-old male during a routine check-up. Based on Tanner's stages of sexual development, which of the following characteristics would the nurse expect to observe in a male at Tanner stage 3?
A. Enlargement of the testes and scrotum with the appearance of pubic hair
Enlargement of the testes and scrotum with the appearance of pubic hair is characteristic of Tanner stage 2, which marks the early stages of puberty. This is when initial changes in the genitalia and pubic hair begin.
B. Penile enlargement and deepening of the voice
Penile enlargement and deepening of the voice is correct because these changes occur during Tanner stage 3, representing continued pubertal development. Stage 3 includes further growth of the penis, continued enlargement of the testes, increased pubic hair that is darker and coarser, and the beginning of voice changes.
C. Increased muscle mass and facial hair growth
Increased muscle mass and facial hair growth is incorrect because these changes are more characteristic of Tanner stage 4–5, the later stages of puberty, when secondary sexual characteristics become more pronounced.
D. Full development of genitalia and the growth of axillary hair
Full development of genitalia and the growth of axillary hair is incorrect because this represents Tanner stage 5, which indicates full sexual maturity and adult genital development.
Full Explanation
A. Enlargement of the testes and scrotum with the appearance of pubic hair is characteristic of Tanner stage 2, which marks the early stages of puberty. This is when initial changes in the genitalia and pubic hair begin.
B. Penile enlargement and deepening of the voice is correct because these changes occur during Tanner stage 3, representing continued pubertal development. Stage 3 includes further growth of the penis, continued enlargement of the testes, increased pubic hair that is darker and coarser, and the beginning of voice changes.
C. Increased muscle mass and facial hair growth is incorrect because these changes are more characteristic of Tanner stage 4–5, the later stages of puberty, when secondary sexual characteristics become more pronounced.
D. Full development of genitalia and the growth of axillary hair is incorrect because this represents Tanner stage 5, which indicates full sexual maturity and adult genital development.
A nurse is assessing a newborn who is 12 hours old. The infant's total serum bilirubin is 13 mg/dL and jaundice is visible on the face and chest. The nurse knows this level is most likely
Full Explanation
Pathologic jaundice (Select 1): The most critical factor here is that the jaundice appeared within the first 24 hours of life. Physiologic jaundice typically appears after 24 hours, peaks between days 3–5, and usually does not reach levels as high as 13 mg/dL so rapidly. A level of 13 mg/dL at only 12 hours old is significantly elevated and indicates a rapid rise, which is characteristic of pathologic conditions like Rh/ABO incompatibility or sepsis.
Phototherapy (Select 2): This is the first-line medical intervention for significant hyperbilirubinemia. It uses light energy to change unconjugated bilirubin into a water-soluble form (lumirubin) that can be excreted in the bile and urine without needing to be processed by the liver.