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 ["A","C","D"]

Explanation

A. Ensure the child is placed on droplet precautions is the priority because bacterial meningitis is highly contagious. Droplet precautions help prevent the spread of the infection to others in the hospital.

B. Encouraging the child to drink plenty of fluids is not the priority in the acute phase of meningitis, as increased fluid intake may not be appropriate, especially if there is elevated intracranial pressure or vomiting. Fluid management should be carefully monitored by the healthcare team.

C. Administering intravenous antibiotics is crucial because bacterial meningitis requires prompt treatment with antibiotics to prevent complications and reduce mortality.

D. Providing comfort measures such as dimming the lights is important because the child may be sensitive to light, noise, and stimuli. A calm, quiet environment can help reduce discomfort and manage symptoms like headache and photophobia.

E. Preparing the child for a CT scan of the head might be indicated if there are signs of increased intracranial pressure, but it is not the immediate priority. Initial treatment with antibiotics and managing the environment are higher priorities.

A. "Palliative care serves to hasten death and make the process easier for the family." B. "Palliative care provides pain and symptom management and best quality of life for the child." C. "The goal of palliative care is to place the child in a hospice setting at the end of life." D. "The goal of palliative care is to act as the liaison between the family, child, and other health care professionals."

Correct Answer is B

Explanation

A. Palliative care serves to hasten death and make the process easier for the family is an incorrect statement. Palliative care is focused on providing relief from symptoms and improving the quality of life, not hastening death.

B. Palliative care provides pain and symptom management and best quality of life for the child is the correct understanding of palliative care. It focuses on managing symptoms and providing support to improve quality of life, regardless of the child’s age or stage of illness.

C. The goal of palliative care is to place the child in a hospice setting at the end of life is not entirely correct. Palliative care can be provided at any stage of a serious illness, not just at the end of life, and it does not automatically mean placement in hospice.

D. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals is a supportive role, but it does not fully define the scope of palliative care, which is focused on symptom management and improving quality of life.

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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?

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Explanation

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