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 A
Explanation
In a teaching plan for the mother of an 11-year-old boy with ulcerative colitis, the nurse should stress the importance of coping with stress and avoiding triggers. Ulcerative colitis is a chronic inflammatory bowel disease that can be influenced by various factors, including stress and triggers. Helping the child and the family develop effective stress management strategies and identifying and avoiding triggers can help in reducing the frequency and severity of ulcerative colitis flare-ups.
preventing the spread of illness to others in (option B) is incorrect because it, is not the primary focus of teaching for ulcerative colitis. Ulcerative colitis is not an infectious condition that can be spread to others.
, nutritional guidance and supportive intake of sodas in (option C) is incorrect because it, is an important aspect of managing ulcerative colitis. However, it should be addressed in conjunction with a comprehensive nutritional plan that considers the individual needs and tolerances of the child. The mention of supportive intake of sodas may not be appropriate, as carbonated beverages can potentially aggravate symptoms in some individuals with ulcerative colitis.
teaching daily use of enemas in (option D) is incorrect because it, is not typically a part of routine care for ulcerative colitis in children. The use of enemas may be considered in specific situations or as part of an individualized treatment plan under the guidance of healthcare providers, but it is not a general teaching point for all children with ulcerative colitis.
Correct Answer is A
Explanation
During adolescence, there is a period of rapid physical growth and development. This growth spurt requires additional energy and resources from the body, which can lead to increased fatigue and a heightened need for sleep. The body utilizes sleep as a time for rest, repair, and growth, and during this growth phase, the demand for restorative sleep tends to increase.
decreased activity in (option B) is incorrect because it, does not necessarily contribute to an increased need for sleep. While decreased activity may result in less fatigue and the perception of needing less sleep, it is not a predisposing factor for feeling an increased need for sleep.
typical lack of ambition in (option C) is incorrect because it, is not associated with an increased need for sleep. Lack of ambition refers to a lack of motivation or drive, which is not directly related to the physiological need for sleep.
an inadequate diet in (option D) is incorrect because it, can affect overall health and well- being, but it is not specifically associated with an increased need for sleep. However, a well- balanced and nutritious diet can support healthy growth and development, including adequate sleep patterns.
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