A 6-month-old infant with hydrocephalus is admitted to the hospital due to an enlarged head circumference, bulging fontanelles, and sunset eyes. What is the priority nursing care?


•Hydrocephalus can cause an increase in intracranial pressure. To prevent complications of increased ICP, the nurse should assess for: frontal bossing, dilated scalp veins, diplopia, vomiting, tense fontanels, irritability, decreased level of consciousness, and changes in vital signs.

•Increase in intracranial pressure can cause brain stem compression, which could result in respiratory or cardiac failure.

•Measuring head circumference regularly will help indicate if the condition is improving.

•Promoting normal growth and development is not a priority during a severe acute illness.

Visit our website for other NCLEX topics now!