The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.

 

Choice A rationale:

Offering small amounts of clear liquids 6 hours following surgery is generally appropriate, but it doesn't specifically address the child's pain management. Pain control is essential postoperatively, and the best approach is to administer analgesics as prescribed by the healthcare provider.

Choice B rationale:

Applying a warm compress to the operative site once daily can provide comfort and may help reduce localized pain or swelling. However, this alone might not be sufficient for pain management, especially in the immediate postoperative period.

Choice C rationale:

(Correct Choice) Administering analgesics on a scheduled basis for the first 24 hours is essential for managing postoperative pain effectively. Pain can interfere with the child's recovery, breathing, and overall well-being. Scheduled pain medications ensure a consistent level of pain relief, allowing the child to rest and recover more comfortably.

Choice D rationale:

Cromolyn nebulized solution is used to prevent asthma symptoms and allergic reactions. It is not typically indicated for postoperative pain management. Providing appropriate analgesics, as prescribed, is the standard of care for managing pain in a postoperative child.

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.