U world questions:

1. The following 4 clients are brought to the emergency department triage nurse. The
client with which of these signs should be a priority to be seen for immediate care?
a. A 2 year old has sclera visible above the iris (sunset eyes)
b. A 3 year old has a single transverse crease across the entire palm of the hand
c. A 6 month old breastfed client had 8 wet diapers in the last 24 hours
d. A 9 month old client’s toes fan out and the big toe dorsiflexes when the foot sole
is stroked
Ans: 1
The presence of sunset eyes (sclera above iris) is late sign of increased ICP and a priority.
Simian crease (option 2) is expected findings in down syndrome. The normal diaper
count for a 6 month (option 3) is 6-10 diapers/day. Infants have positive Babinski reflex
(option 4) until age 1
˜
This is a sign of 6th cranial nerve palsy (paralysis of upward gaze) as a result of increased
ICP/ hydrocephalus. This is an acute, delayed sign and requires timely priority diagnosis
and treatment. This sign is more likely to be noted after the fontanels have closed
(posterior by 6 months and anterior by 18 months) and the pressure increases.