Test Bank for Saunders Comprehensive Review for the
NCLEX-RN
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. - ANSWERS4
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) - ANSWERS4
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.
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. -
ANSWERS3
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 - ANSWERS4
Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's syndrome.
The nurse is providing home care instructions to the mother of a child who is recovering from
Reye's syndrome. Which of the following home instructions should the nurse provide to the
mother?
1. Increase the stimuli in the environment.
, 2. Give the child frequent small meals, if vomiting occurs.
3. Avoid daytime naps so that the child will sleep at night.
4. Check the child's skin and eyes every day for a yellow discoloration. - ANSWERS4
Rationale: Checking for jaundice will assist in identifying the presence of liver complications,
which are characteristic of Reye's syndrome. If vomiting occurs in Reye's syndrome, it is caused
by cerebral edema and is a sign of intracranial pressure. Decreasing stimuli and providing rest
decrease stress on the brain tissue.
The nurse working in the day care center is told that a child with autism will be attending the
center. The nurse collaborates with the staff of the day care center and assists in planning
activities that will meet the child's needs. The nurse understands that the priority consideration
in planning activities for the child is to ensure:
1. Safety with activities
2. Activities providing verbal stimulation
3. Social interactions with other children in the same age group
4. Familiarity with all activities and providing orientation throughout the activities - ANSWERS1
Rationale: Safety with all activities is a priority in planning activities with the child. The child
with autism is unable to anticipate danger, has a tendency for self-mutilation, and has
sensoriperceptual deficits.
The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the
control of seizures. Which of the following statements, if made by the adolescent, indicates a
need for further teaching regarding the medication?
1. "The medication may cause oily skin."
2. "Drinking alcohol may affect the medication."
3. "If my gums become sore I need to stop the medication."
4. "Birth control pills may not be effective when I take this medication." - ANSWERS3
Rationale: The adolescent should not stop taking antiseizure medications suddenly or without
discussing it with a physician or nurse.
NCLEX-RN
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. - ANSWERS4
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) - ANSWERS4
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.
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. -
ANSWERS3
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 - ANSWERS4
Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's syndrome.
The nurse is providing home care instructions to the mother of a child who is recovering from
Reye's syndrome. Which of the following home instructions should the nurse provide to the
mother?
1. Increase the stimuli in the environment.
, 2. Give the child frequent small meals, if vomiting occurs.
3. Avoid daytime naps so that the child will sleep at night.
4. Check the child's skin and eyes every day for a yellow discoloration. - ANSWERS4
Rationale: Checking for jaundice will assist in identifying the presence of liver complications,
which are characteristic of Reye's syndrome. If vomiting occurs in Reye's syndrome, it is caused
by cerebral edema and is a sign of intracranial pressure. Decreasing stimuli and providing rest
decrease stress on the brain tissue.
The nurse working in the day care center is told that a child with autism will be attending the
center. The nurse collaborates with the staff of the day care center and assists in planning
activities that will meet the child's needs. The nurse understands that the priority consideration
in planning activities for the child is to ensure:
1. Safety with activities
2. Activities providing verbal stimulation
3. Social interactions with other children in the same age group
4. Familiarity with all activities and providing orientation throughout the activities - ANSWERS1
Rationale: Safety with all activities is a priority in planning activities with the child. The child
with autism is unable to anticipate danger, has a tendency for self-mutilation, and has
sensoriperceptual deficits.
The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the
control of seizures. Which of the following statements, if made by the adolescent, indicates a
need for further teaching regarding the medication?
1. "The medication may cause oily skin."
2. "Drinking alcohol may affect the medication."
3. "If my gums become sore I need to stop the medication."
4. "Birth control pills may not be effective when I take this medication." - ANSWERS3
Rationale: The adolescent should not stop taking antiseizure medications suddenly or without
discussing it with a physician or nurse.
