The nurse is caring for a 10-year-old who has an acute head injury, has a pediatric Glasgow coma score of 9. and is unconscious. Which interventions should the nurse include in the child's care plan?

Pilonidal dimpling with the presence of an abnormal tuft of hair in or near the dimple

Explanation:

Spina bifida is a congenital condition where there is incomplete closing of the backbone and membranes around the spinal cord during early development in the womb. Pilonidal dimpling with the presence of an abnormal tuft of hair in or near the dimple is a specific sign of spina bifida. This condition is called "sacral dimple," and it can indicate an underlying issue with the spinal cord and nerves. An abnormal tuft of hair in or near the dimple suggests a neural tube defect, which is characteristic of spina bifida.

Why the other choices are incorrect:

A. complete paralysis:

Complete paralysis is a severe neurological symptom but it is not specific to spina bifida. It can occur due to various other conditions as well, such as spinal cord injuries, infections, and neurological disorders. It's not a characteristic sign of spina bifida.

B. Petechiae:

Petechiae are small, red or purple spots on the skin that are caused by bleeding under the skin. They are usually associated with bleeding disorders, infections, or other medical conditions. Petechiae are not a characteristic sign of spina bifida.

C. Abnormal Vital Signs:

While spina bifida can potentially lead to neurological complications that might influence vital signs, the presence of abnormal vital signs is a non-specific symptom. Abnormal vital signs could be caused by a wide range of medical conditions, and they are not directly indicative of spina bifida.

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.