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
Hypothyroidismreferstoanunderactivethyroid glandthatdoesnotproduceenoughthyroidhormones. In newborns, this condition is known as congenital hypothyroidism. Thesymptoms mentioned—mottled skin, a large fontanel (soft spot on the baby's head), a largetongue,lethargy, anddifficultyfeeding—arecharacteristic ofhypothyroidism inneonates.
Mottledskincanoccur duetodecreasedcirculationandlow bodytemperatureassociatedwith hypothyroidism. A large fontanel and tongue are common physical features seen ininfants with hypothyroidism. Lethargy and poor feeding are also typical signs of thiscondition.
Hypoglycaemia in (option A) is incorrect because it refers to low blood sugar levels andusuallypresentswithdifferent symptomssuchas jitteriness,tremors,and sweating.
Hypocalcaemia in (option C) is incorrect because it is low calcium levels and can manifestwithsymptoms like muscle cramps, twitching,and seizures.
Phenylketonuria (PKU) in (option D) it is incorrect because it is a metabolic disordercharacterized by the inability to metabolize the amino acid phenylalanine, and it typicallypresentswith differentsymptoms such asintellectual disabilityandamustydoorto theskin.
Therefore, based on the symptoms described, hypothyroidism (B) is the most likely disorderinthisneonate. Itisimportanttoconsultahealthcareprofessionalforaproperdiagnosisandappropriatetreatment.
Correct Answer is A
Explanation
A subdural hematoma is a type of intracranial bleeding that occurs between the dura mater (the
outermost layer of the meninges) and the skull. The dura mater is a tough membrane that covers
and protects the brain. When a subdural hematoma occurs, blood collects between the dura mater
and the skull, resulting in increased pressure on the brain.
Bleeding is generally arterial, and brain compression occurs rapidly in (Option B) is incorrect because
while bleeding in a subdural hematoma can be arterial, it can also be venous. The rate of bleeding
and brain compression can vary depending on the size and severity of the hematoma.
Bleeding occurs between the dura and the cerebrum in (Option C) is incorrect because the bleeding
in a subdural hematoma does not occur between the dura and the cerebrum (the largest part of the
brain). It specifically occurs between the dura and the skull.
The hematoma commonly occurs in the pretemporal region in (Option D) is incorrect because the
location of a subdural hematoma can vary. While pretemporal region is a possible location, subdural
hematomas can occur in different areas of the brain, depending on the site of injury.
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