A nurse is caring for a child who has been diagnosed with a concussion. Which of the following findings should the nurse identify as causing this type of injury?

A deep wound that caused external bleeding on the head and face

Trauma from contact sports that caused the brain to twist or bounce against the skull

A blow to the head that caused diffuse bleeding between the skull and brain

A fall that caused blood from a ruptured artery to pool in the brain

Answer and Explanation

The Correct Answer is B

A. A deep wound causing external bleeding does not describe a concussion, which involves a brain injury due to trauma, not a superficial wound.

B. A concussion is a mild traumatic brain injury caused by a blow to the head or trauma that causes the brain to twist or bounce inside the skull. This movement can lead to temporary neurological impairment.

C. Bleeding between the skull and brain (epidural hematoma or subdural hematoma) is associated with more severe traumatic brain injuries, not a concussion.

D. A ruptured artery leading to pooling of blood in the brain is more characteristic of an intracerebral hemorrhage or a severe head injury, not a concussion.

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Correct Answer is C

Explanation

A. Increased temperature, tachycardia, tachypnea is not consistent with Cushing's triad. These signs generally reflect an infection, fever, or a stress response, and are not indicative of increased intracranial pressure (ICP) or brain herniation.

B. Decreased temperature, bradycardia, bradypnea is incorrect. While bradycardia is a component of Cushing's triad, decreased temperature and bradypnea are not part of this syndrome. The signs of Cushing's triad typically include increased blood pressure, not decreased temperature.

C. Bradycardia, high blood pressure, irregular respirations is correct. These are the hallmark signs of Cushing's triad, which indicate a significant increase in intracranial pressure. Bradycardia occurs as a result of elevated pressure on the brainstem, high blood pressure develops as a compensatory mechanism to maintain perfusion, and irregular respirations reflect brainstem dysfunction.

D. Bradycardia, hypotension, tachypnea is incorrect. Hypotension is not part of Cushing's triad. Instead, high blood pressure is typically present in this condition due to the body's compensatory response to increased ICP.

A. "Intussusception occurs when one segment of the intestine slides into another, which can cut off blood supply." B. "Intussusception results from the twisting of the intestine, causing a blockage in the passage of food." C. "Intussusception is a congenital condition where the layers of the intestinal wall do not form properly." D. "Intussusception is a consequence of weakened abdominal muscles, allowing a portion of the intestine to bulge."

Correct Answer is A

Explanation

A. "Intussusception occurs when one segment of the intestine slides into another, which can cut off blood supply." is the correct explanation. Intussusception occurs when a part of the intestine telescopes into an adjacent section, causing a blockage that can cut off blood supply and lead to tissue death. This is a medical emergency requiring prompt treatment.

B. "Intussusception results from the twisting of the intestine, causing a blockage in the passage of food." is incorrect. While intussusception causes a blockage, it does not result from twisting; it involves one segment of the intestine sliding into another.

C. "Intussusception is a congenital condition where the layers of the intestinal wall do not form properly." is incorrect. Intussusception is not congenital in nature; it can occur in otherwise healthy infants and children but is not a result of improper formation of the intestinal wall layers.

D. "Intussusception is a consequence of weakened abdominal muscles, allowing a portion of the intestine to bulge." is inaccurate. Intussusception does not result from weakened abdominal muscles but rather from one part of the intestine slipping into another, which may cause the blockage and reduced blood flow.

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A nurse is caring for a child who has been diagnosed with a concussion. Which of the following findings should the nurse identify as causing this type of injury?

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