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 A
Explanation
The nurse's best response to the parents of a 10-year-old child newly diagnosed with type 1
diabetes mellitus, who are concerned about the child's continued participation in soccer, is to
reassure them that it is generally safe for the child to play sports such as soccer unless the
weather is too hot.
Regular physical activity, including participation in sports, is generally encouraged for
children with type 1 diabetes as long as certain precautions are taken. It is important for the
child to have a well-managed diabetes management plan in place, which may include
monitoring blood sugar levels before, during, and after physical activity, adjusting insulin
doses as necessary, and having appropriate snacks available to maintain blood sugar levels.
Option B, suggesting the swim team as an alternative to soccer, may be a viable option if the
child or parents prefer swimming or if the child has specific concerns related to soccer.
However, it is not the best response to the parents' concern about the child's continued
participation in soccer.
Option C, recommending an extra carbohydrate snack before soccer practice, is a valid
suggestion to help maintain the child's blood sugar levels during physical activity. However,
it should be part of a comprehensive diabetes management plan and not the sole response to
the parents' concern.
Option D, encouraging intellectual activity rather than participation in sports, is not
appropriate as physical activity is generally beneficial for children with type 1 diabetes, as
long as appropriate precautions are taken.
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.
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