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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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.
Correct Answer is C
Explanation
When caring for a child with an open fracture, the nurse should carefully assess for signs and symptoms of infection. An open fracture refers to a fracture where the bone is exposed through the skin, creating a direct pathway for microorganisms to enter and cause infection. Infection is a significant concern in open fractures and can lead to serious complications if not identified and treated promptly. Signs of infection may include increased pain, swelling, redness, warmth, purulent drainage, fever, or systemic signs of infection such as elevated white blood cell count.
Osteoarthritis in (option A) is incorrect because it, is not an immediate concern in the care of a child with an open fracture. Osteoarthritis refers to degenerative joint disease that typically develops over time and is not directly related to the acute management of an open fracture.
epiphyseal disruption in (option B) is incorrect because it, refers to an injury involving the growth plate (epiphyseal plate) that can affect bone growth and development. While it is a potential concern in fractures that involve the growth plate, it is not specific to open fractures and may not be an immediate priority in the initial assessment of an open fracture.
periosteum thickening in (option D) is incorrect because it, may occur in response to injury and fracture healing, but it is not specifically associated with open fractures and is not a primary focus in the initial assessment of an open fracture.
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