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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When the skin surface is caked with desquamated skin and sebaceous secretions after the removal of a cast, the nurse should suggest washing the area with warm water and soap. This will help to gently cleanse the skin and remove the accumulated material without causing unnecessary trauma or irritation.
Option A, applying powder to absorb the material, may not effectively remove the caked material and could potentially lead to further clumping or discomfort.
Option B, vigorously scrubbing the leg, can be harsh on the skin and may cause skin irritation, redness, or even abrasions. It is important to be gentle and avoid excessive scrubbing, especially on the fragile and recently exposed skin.
Option C, carefully picking the material off the leg, can increase the risk of skin injury or introduce bacteria into the skin. Picking at the skin should be avoided to prevent further damage or infection.
Therefore, option D, washing the area with warm water and soap, is the most appropriate and gentle method to remove the caked material from the skin surface
Correct Answer is B
Explanation
Juvenile arthritis should be suspected in a child who exhibits joint swelling and pain lasting
longer than 6 weeks. Juvenile arthritis refers to a group of chronic inflammatory conditions
that affect the joints in children and adolescents. Persistent joint swelling and pain are
common symptoms of juvenile arthritis and are often accompanied by other signs such as
morning stiffness, limited range of motion, and joint warmth.
, frequent fractures in (option A) is not correct because it, is not typically associated with
juvenile arthritis. Fractures are more commonly associated with conditions affecting bone
strength, such as osteoporosis or certain genetic disorders.
lurching and abnormal gait with limited abduction in (option A) is not correct because it,
may be seen in certain musculoskeletal conditions or hip joint abnormalities, but it is not
specific to juvenile arthritis.
increased joint mobility in (option D) is incorrect because it, is not typically associated with
juvenile arthritis. In fact, joint stiffness and limited range of motion are more characteristic of
this condition.
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