Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

Confusion and altered mental status

Increased diastolic pressure with narrowing pulse pressure

Irregular, rapid heart rate

Rapid, shallow breathing

Answer and Explanation

The Correct Answer is A

A change in status that should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury is confusion and altered mental status. As intracranial pressure increases, it can affect brain function and lead to neurological changes, including confusion, disorientation, irritability, decreased level of consciousness, or other alterations in mental status. These changes indicate that the brain is being compressed and compromised, and immediate intervention is required.

Option B, increased diastolic pressure with narrowing pulse pressure in (option B) is incorrect because it, can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or systemic conditions. It is important to consider the overall hemodynamic status of the child and assess for additional signs and symptoms of increased ICP.

irregular, rapid heart rate in (option C), can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or other medical conditions. Assessment of heart rate should be considered along with other signs and symptoms of increased ICP.

rapid, shallow breathing, in (option D) can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or respiratory conditions. Respiratory assessment should be considered along with other signs and symptoms of increased ICP.

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Correct Answer is B

Explanation

The term used to describe an abnormally increased convex angulation in the curvature of the thoracic spine, which appears as a "hump back" or rounded upper back, is kyphosis.

Kyphosis refers to an excessive forward rounding or curvature of the thoracic spine, leading to a visible hump-like appearance. It can result from various causes, including poor posture, congenital abnormalities, osteoporosis, or certain medical conditions.

ankylosis in (option A), refers to the abnormal fusion or immobility of a joint, typically due to inflammation or injury.

Lordosis, in (option C) refers to an excessive inward curvature of the lower back, causing the abdomen and buttocks to protrude.

, scoliosis in (option D), refers to an abnormal sideways curvature of the spine, typically in an "S" or "C" shape. It is different from kyphosis, which primarily affects the thoracic spine and results in a rounded upper back.

A. His caloric intake would have to be excessive for him to gain weight. B. He is substituting food for unfilled needs. C. This is normal because of increase in body mass during this time. D. This is abnormal and suggestive of possible future obesity.

Correct Answer is A

Explanation

The scenario describes a 14-year-old male who seems to be always eating, but his weight is appropriate for his height. In this case, it is important to reassure the parents that the behaviour may not necessarily be a cause for concern.

Option A provides an accurate response by explaining that for weight gain to occur, the individual would need to consume an excessive number of calories. Since the adolescent's weight is appropriate for his height, it suggests that his caloric intake is likely balanced and not excessive.

suggesting that he is substituting food for unfilled needs in (option B) is incorrect because it, is speculative and may not be accurate without further assessment or evidence. It is important to avoid making assumptions about underlying psychological or emotional reasons for increased eating without more information.

stating that this is normal due to an increase in body mass during this time in (option C) is incorrect because it, is not necessarily applicable to the scenario. While it is true that adolescents experience growth and changes in body composition during this period, it does not directly explain the constant eating behaviour described.

suggesting that this behaviour is abnormal and indicative of possible future obesity in (option D) is incorrect because it, may be premature and unsupported based solely on the information provided. It is essential to avoid making predictions or assumptions about future health outcomes without proper evaluation.

By providing the parents with information about the caloric intake required for weight gain and reassuring them that their son's eating behaviour may be within a normal range, the nurse can address their concerns and provide accurate guidance. If the parents have further concerned or questions, it may be appropriate to refer them to a healthcare provider for a more comprehensive assessment.

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Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

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Naxlex Comprehensive Predictor Exams

Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine. looks like a "hump back?

Correct Answer is B

Explanation

A 14-year-old male seems to be always eating, although his weight is appropriate for his height. The parents ask the nurse if they should be concerned about this behaviour. Which response by the nurse is best?

Correct Answer is A

Explanation

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