Page 928 - Saunders Comprehensive Review For NCLEX-RN

▪ Tense, bulging fontanel

▪ Separated cranial sutures
▪ Macewen’s sign (cracked-pot sound on percussion)
▪ Irritability
▪ High-pitched cry
▪ Increased head circumference
▪ Distended scalp veins
▪ Poor feeding
▪ Crying when disturbed
▪ Setting sun sign (eyes appear downward, with the sclera seen over the iris, part
of the lower pupil may be covered by the lower eyelid)

Children

▪ Headache
▪ Nausea
▪ Forceful vomiting
▪ Diplopia; blurred vision
▪ Seizures

Personality and Behavior Signs

▪ Irritability, restlessness
▪ Indifference, drowsiness
▪ Decline in school performance
▪ Diminished physical activity and motor performance
▪ Increased sleeping
▪ Inability to follow simple commands
▪ Lethargy

Late Signs

▪ Bradycardia
▪ Decreased motor response to command

▪ Decreased sensory response to painful stimuli
▪ Alterations in pupil size and reaction
▪ Decerebrate (extension) or decorticate (flexion) posturing
▪ Cheyne-Stokes respirations
▪ Papilledema
▪ Decreased consciousness
▪ Coma

928