Practice Question
When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder?
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Correct Answer:
Hydrocephalus
Rationale:
🧠 Hydrocephalus results from an imbalance between the production and absorption of cerebrospinal fluid (CSF), leading to ventricular dilation and increased intracranial pressure (ICP).
🧠 In infants, the open fontanels allow the head to expand, so early signs include rapid head circumference growth, bulging fontanels, distended scalp veins, vomiting, irritability, and poor feeding.
🧠 Early detection is vital, as progressive hydrocephalus can cause neurological damage.
🧠 Management typically involves surgical placement of a ventriculoperitoneal (VP) shunt, which redirects CSF from the ventricles to the peritoneum for absorption.
🧠 Nurses play a key role in monitoring for signs of shunt malfunction, such as vomiting, drowsiness, or seizure activity.
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This question is from RN ATI Paediatrics Exam VIII which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4