A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased Intracranial pressure?

A. Elevated blood glucose is remarkable with Cushing's Triad:

Elevated blood glucose is not one of the components of Cushing's Triad. The triad focuses on cardiovascular and respiratory changes associated with increased intracranial pressure, not blood glucose levels.

B. Cushing's Triad includes a positive Macawen's sign:

Macawen's sign is not part of Cushing's Triad. Cushing's Triad is specifically related to the physiological responses seen in response to increased intracranial pressure and is not associated with Macawen's sign.

C. Cushing's Triad includes tachycardia, seizures and rapid respirations:

This option is not accurate. Cushing's Triad involves bradycardia (slow heart rate), irregular respirations, and a widening pulse pressure. Tachycardia (rapid heart rate) and seizures are not part of Cushing's Triad but might be indicative of other medical conditions or complications.

D. Bradycardia, irregular respirations and a widening pulse pressure.

Explanation: Cushing's Triad is a set of three clinical signs that are indicative of increased intracranial pressure (ICP) and are considered ominous as they suggest serious brain injury or pathology. The triad consists of:

Bradycardia: This refers to a slow heart rate. As intracranial pressure increases, it can lead to a decreased heart rate due to pressure on the brainstem, which is involved in regulating heart rate.

Irregular Respirations: Increased ICP can affect the brainstem's control over breathing, leading to irregular patterns of breathing, often known as Cheyne-Stokes respiration. This is characterized by periods of rapid breathing followed by apnea (temporary cessation of breathing).

Widening Pulse Pressure: Pulse pressure is the difference between systolic and diastolic blood pressure. An increase in ICP can cause an increase in systolic blood pressure and a decrease in diastolic blood pressure, leading to a widening pulse pressure.

A) "I can store unopened bottles of insulin in the freezer."

This statement is incorrect. Insulin should not be stored in the freezer. Insulin should be stored in the refrigerator, and the currently used vial can be kept at room temperature for up to 28 days to avoid the discomfort of injecting cold insulin.

B) "I should not take my regular insulin when I am sick."

This statement is incorrect. When a person with type 1 diabetes is sick, it's important to continue taking insulin. In fact, during illness, blood sugar levels can become more difficult to manage, and insulin may be needed in adjusted doses. Skipping insulin during sickness can lead to uncontrolled blood sugar levels and potentially worsen the illness.

C) "My morning blood glucose should be between 90 and 130."

This statement is a good range to aim for in terms of fasting blood glucose levels, but it's not an indication of understanding the teaching about diabetes management as a whole. While this knowledge is important, the statement about eating a snack before playing soccer directly reflects understanding of how to manage blood sugar during physical activity.

"D) I should eat a snack half an hour before playing soccer."

Explanation:

Managing blood sugar levels is crucial for individuals with type 1 diabetes, especially when engaging in physical activities like playing soccer. Eating a snack before playing helps prevent hypoglycemia (low blood sugar) during exercise. Physical activity can cause the body to use up glucose faster, potentially leading to low blood sugar levels, and having a snack before exercise can help maintain stable blood sugar levels.