A child with a head injury is at risk for increased intracranial pressure (ICP). Which change in status would alert the nurse to believe an increase in ICP has occurred?

Confusion and altered mental status

Increased diastolic pressure with narrowing pulse pressure

Irregular, rapid heartbeat

Rapid, shallow breathing

Answer and Explanation

The Correct Answer is B

A. Confusion and altered mental status can be signs of increased ICP, but these symptoms are not specific. Confusion or altered consciousness may also be observed in other conditions, so this alone may not definitively indicate increased ICP.

B. Increased diastolic pressure with narrowing pulse pressure is a classic sign of increased intracranial pressure and is a key component of Cushing's triad. This triad, which also includes bradycardia and irregular respirations, is a critical indicator of impending brain herniation and requires immediate intervention.

C. Irregular, rapid heartbeat is not a direct sign of increased ICP. While heart rate changes can occur with changes in ICP, they are usually seen as part of Cushing’s triad and would typically present with bradycardia, not rapid heartbeat.

D. Rapid, shallow breathing can occur in response to other conditions, but it is not the most specific or early sign of increased ICP. Changes in the respiratory pattern with increased ICP often involve more distinct alterations like Cheyne-Stokes or irregular breathing patterns.

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Correct Answer is B

Explanation

A. The tumor is located in the lower back of the brain in the midline posterior fossa is incorrect. This description is more characteristic of a cerebellar or brainstem tumor, not neuroblastoma.

B. The tumor originated in the adrenal glands is correct. Neuroblastoma typically arises from the adrenal glands, though it can also develop in nerve tissue along the spine, neck, chest, or pelvis.

C. The tumor has not spread to other areas of the child's body is incorrect. Neuroblastoma often metastasizes to other parts of the body, such as the bones, lymph nodes, liver, and skin.

D. The tumor came from malformation of astrocyte glial brain cells is incorrect. This describes gliomas, which are a different category of brain tumors, not neuroblastoma.

A. No venipuncture or blood pressure in left arm B. Do not palpate abdomen. C. Collect all urine. D. Contact precautions

Correct Answer is B

Explanation

A. No venipuncture or blood pressure in left arm is incorrect. This instruction is often associated with patients who have a shunt, a limb with an established intravenous line, or another condition, but it is not specific to Wilms' tumor.
B. Do not palpate abdomen is correct. Wilms' tumor is a type of kidney cancer in children, and the tumor is often palpable in the abdomen. Palpating the abdomen could cause the tumor to rupture, leading to the spread of cancerous cells. To avoid this risk, the abdomen should not be palpated.
C. Collect all urine is incorrect. While urine collection might be necessary for monitoring renal function or assessing signs of metastasis, it is not a standard precaution or warning for a child with Wilms' tumor.
D. Contact precautions is incorrect. Wilms' tumor is not contagious, so contact precautions are not required unless there is a coexisting infectious condition.

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A child with a head injury is at risk for increased intracranial pressure (ICP). Which change in status would alert the nurse to believe an increase in ICP has occurred?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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