which condition is most commonly associated with a sunset sign in infants
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. Which condition is most commonly associated with a 'sunset sign' in infants?

Correct answer: A

Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'

2. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?

Correct answer: A

Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.

3. At which age can most infants sit steadily unsupported?

Correct answer: C

Rationale: Most infants can sit steadily without support by 8 months, indicating advanced gross motor skill development.

4. An important role of the nurse in ambulatory settings and schools is the identification of communicable diseases for treatment and the prevention of spread. What is an important component related to the first period of the contagiousness of disease?

Correct answer: C

Rationale: The prodromal period is the interval between the early manifestations of the disease and the time when the overt clinical syndrome is evident. Most communicable diseases are contagious during this time. Identifying the prodromal stage is crucial for early intervention and preventing the spread of the disease. While the source and causative agent are important aspects of disease control, recognizing the early signs in the prodromal stage allows the nurse to take timely actions. Constitutional symptoms occur during the active disease phase, indicating that the child has already been contagious, and early intervention opportunities may have passed.

5. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)

Correct answer: C

Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.

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