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 student nurse regarding why peer relationships become more important during adolescence is option A. Peer relationships become significant during adolescence because they provide adolescents with a sense of belonging. During this developmental stage, adolescents are transitioning from a primary focus on their family to a greater emphasis on peer interactions and social connections. Peer relationships offer a sense of acceptance, support, and identity as adolescents strive to establish their own identities separate from their families.
adolescents dislike their parents in (option B), is not a correct or comprehensive explanation for the increased importance of peer relationships during adolescence. While it is common for parent-child conflicts to arise during this stage, it does not imply that adolescents dislike their parents as a general rule.
suggesting that adolescents no longer need parental control in (option C), is not correct. While adolescents are seeking increased independence and autonomy, they still require parental guidance and support. Parental control and involvement continue to be essential in providing a secure and nurturing environment during adolescence.
They promote a sense of individuality in adolescents in (option D), is incorrect. Peer relationships do contribute to the development of individuality by allowing adolescents to explore their own interests, values, and social roles. However, the primary reason for the increased importance of peer relationships during adolescence is the sense of belonging and social acceptance they provide.
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.
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