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 C
Explanation
A sign of increased intracranial pressure (ICP) in a 10-year-old child is a headache. Headache is a common symptom associated with increased pressure within the cranial cavity. It can be a result of various conditions that cause elevated intracranial pressure, such as brain tumours, intracranial haemorrhage, hydrocephalus, or brain trauma. The headache may be described as persistent, worsening, or accompanied by other symptoms such as nausea, vomiting, or changes in neurological status.
tachypnoea (rapid breathing), in (option A) is incorrect because it is not a specific sign of increased intracranial pressure. It can be seen in various conditions, including respiratory and cardiovascular disorders, anxiety, or physical exertion.
bulging fontanel in (option B) is incorrect because it, is more commonly observed in infants and is not typically seen in older children. The fontanelles (soft spots) on an infant's skull normally close by the age of 18-24 months.
an increase in head circumference in (option D) is incorrect because it, may be a sign of increased intracranial pressure in infants. However, in a 10-year-old child, the fontanelles are typically closed, and head circumference growth is not a reliable indicator of increased intracranial pressure
Correct Answer is B
Explanation
During this stage, adolescents typically experience a shift from a primary focus on family to
an increased emphasis on peer relationships. However, it is still important for adolescents to
maintain a connection with their family and enjoy spending time with family members. This
behaviour indicates a healthy balance between peer interactions and maintaining positive
relationships with family.
The adolescent is self -absorbed and self-centred and has sudden mood swings in (option A)
is incorrect because it describes behaviours associated with emotional and psychological
challenges commonly seen in adolescence but does not indicate appropriate psychosocial
development.
The adolescent seeks validation for socially acceptable behaviour from older adults in (option
C) is incorrect because seeking validation for socially acceptable behaviour from older adults,
may indicate a lack of autonomy and difficulty in developing a sense of personal identity,
which is important for healthy psychosocial development in adolescence.
Conformity with the peer group increases in late adolescence in (Option D) is incorrect
because stating that conformity with the peer group increases in late adolescence, is not
entirely accurate. While peer influence is significant during adolescence, there is also a
growing emphasis on individuality and the development of one's own identity. Adolescents
may experience a balance between conforming to certain aspects of their peer group and
asserting their unique traits and interests.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.