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
Precocious puberty is the early onset of puberty before the age of 8 in girls and before the age of 9 in boys. It is important for parents of a child with precocious puberty to understand theimpact it may have on their child's social and emotional development. In this case, explaining the importance of the child having relationships with same-age peers is crucial.
Children experiencing precocious puberty may appear physically more mature than their peers, which can lead to social and emotional challenges. Encouraging the child to maintain relationships with same-age peers helps foster a sense of normalcy and belonging. It can also support the child's social and emotional development by providing opportunities for age- appropriate interactions, friendships, and experiences.
Correct Answer is B
Explanation
The best response for the nurse to give a parent regarding contacting the physician about an
infant with diarrhea is option B. In infants, dehydration can occur quickly, and a decrease in
urine output is an important indicator of fluid imbalance. Not having a wet diaper for 6 hours
can be a sign of inadequate fluid intake or excessive fluid loss, which warrants contacting the
paediatrician for further assessment and guidance.
"Call the doctor immediately if the infant has a temperature greater than 100° F,"in (option
A) is incorrect because it is not directly related to the concern of diarrhea. While a high fever
can be a sign of an underlying infection, it is not the primary concern in this case.
"The paediatrician should be contacted if the infant has two loose stools in an 8-hour
period,” in (option B) is incorrect because it may not necessarily require immediate medical
attention. While increased frequency of stools can be concerning, the absence of urine output
is a more critical indicator of dehydration.
"Notify the paediatrician if the infant naps more than 2 hours," in (option D) is incorrect
because it is unrelated to the concern of diarrhea and dehydration.
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