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 B
Explanation
The statement that best describes Tanner staging is option B. Tanner staging is a system used
to classify and assess the progression of puberty based on the development of both primary
and secondary sexual characteristics. It provides a framework for evaluating the physical
changes that occur during puberty, such as breast development in females, testicular
enlargement in males, pubic hair growth, and other secondary sexual characteristics. The
Tanner staging system includes several stages that represent the sequential progression of
puberty in individuals.
staging of puberty based on the initiation of primary sexual characteristics in (option A) is not
correct because it, does not encompass the full scope of Tanner staging, as it does not
consider the progression of secondary sexual characteristics.
staging of puberty based on the initiation of menarche (the onset of menstruation) and
nocturnal emissions, in (option C) is not correct. While menarche and nocturnal emissions are
significant events that occur during puberty, they do not encompass the entire Tanner staging
system, which involves a broader range of physical changes.
predictable stages of puberty based on chronologic age, in (option D) is not correct. Tanner
staging is based on the progression of physical changes and sexual maturation, rather than
being solely determined by chronological age. Puberty can vary in onset and duration among
individuals, making chronological age an unreliable indicator of pubertal development.
Correct Answer is B
Explanation
Precocious puberty is defined as the onset of puberty before the age of 8 in girls and before the age of 9 in boys. However, it is important to note that the exact age at which puberty is considered precocious can vary slightly based on different guidelines and individual variations.
Boys: 11 years; girls: 9 years in (option A) is incorrect because it, is close to the general age range, but it is slightly earlier than what is commonly considered precocious puberty.
Boys: 10 years; girls: 9 1/2 years in (option C) is incorrect because it, is also close to the general age range, but it is not as commonly recognized as the age for precocious puberty.
Boys: 9 years; girls: 8 years in (option D) is incorrect because it, is significantly earlier than the usual age for precocious puberty. Puberty occurring at this age would be considered very early and may warrant further evaluation.
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