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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Diarrhea is characterized by increased motility of the intestines, which leads to a decreased absorption of fluid and nutrients. This statement correctly indicates an understanding of the teaching regarding diarrhea.
Organisms destroy intestinal mucosal cells, resulting in an increased intestinal surface area in (Option A) is incorrect because organisms causing diarrhea can lead to damage or inflammation of the intestinal mucosal cells, but they do not destroy them to increase the intestinal surface area.
Malabsorption results in metabolic alkalosis in (Option B) is incorrect because malabsorption does not result in metabolic alkalosis. Malabsorption refers to the impaired absorption of nutrients, but it does not directly affect the acid-base balance in the body.
Diarrhea results from a fluid deficit in the small intestine in (Option D) is incorrect because diarrhea does not result from a fluid deficit in the small intestine. Diarrhea is characterized by an increased volume of fluid in the intestines and increased frequency of bowel movements.
Correct Answer is D
Explanation
Tanner staging is a method used to assess and describe the development of secondary sexcharacteristics during puberty. It is primarily focused on the physical changes that occur asindividuals transition from childhood to adulthood. The Tanner scale consists of differentstages(ItoV)that describethedevelopmentofspecificsecondarysexcharacteristicssuchasbreastdevelopment, pubichairgrowth,genital development,and facialhair growth.
Growthhormonesecretionin(optionA)isincorrectbecauseWhilegrowthhormonedoesplay a role in the overall growth and development of individuals during puberty, Tannerstagingdoes not specificallymeasureor assessgrowth hormone secretion.
Hormone levels in (option B) is incorrect because While hormone levels, including sexhormonessuchas estrogenandtestosterone, doplayasignificantrolein thedevelopmentofsecondary sex characteristics, Tanner staging itself does not involve measuring or assessinghormone levels. Hormone levels can be assessed through laboratory testing, but this is aseparateprocess from Tanner staging
Hyperthyroidism in (option C) is incorrect because Hyperthyroidism, on the other hand, is amedical condition characterized by an overactive thyroid gland that produces an excessivenumberofthyroidhormones.Itisnotdirectlyrelatedtothedevelopmentofsecondarysexcharacteristics. Diagnosing hyperthyroidism typically involves assessing symptoms,conductingphysicalexaminations,andperformingspecificbloodteststomeasurethyroidhormone levelsandevaluatethyroidfunction.
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