SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX-RN® PART 1 – 2025
QUESTIONS WITH VERIFIED ANSWERS
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. - (answers)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) - (answers)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.
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. - (answers)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 - (answers)4
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.
QUESTIONS WITH VERIFIED ANSWERS
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. - (answers)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) - (answers)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.
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. - (answers)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 - (answers)4
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.
