A child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child which will be the first change noted in the presence of increasing intercranial pressure?
Decline in respiratory rate
Reduction in heart rate
Change in level of consciousness
Increase in heart rate
The Correct Answer is C
A. Changes in respiratory rate, such as irregular or slowed breathing, typically occur later in the course of increasing intracranial pressure (ICP), often indicating severe brainstem involvement. It is not the first sign.
B. Bradycardia is a component of Cushing’s triad (bradycardia, hypertension, and irregular respirations) associated with advanced ICP, not an early sign. Relying on heart rate changes alone may delay recognition of ICP.
C. Altered mental status is the earliest and most sensitive indicator of increasing ICP in children. This can include irritability, restlessness, confusion, or decreased responsiveness. Early recognition of changes in level of consciousness allows prompt intervention to prevent further neurological compromise.
D. Tachycardia is not a primary indicator of rising ICP. Heart rate changes are nonspecific and usually occur secondary to pain, anxiety, or systemic stress, rather than as an early ICP sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Osteomyelitis is a bone infection, not a malignancy. Referral to oncology is unnecessary unless there is an unrelated suspected malignancy. This does not align with standard osteomyelitis discharge planning.
B. Proper nutrition for a child with osteomyelitis should be well-balanced with adequate protein to support tissue repair and immune function. A high-fat, low-protein diet would be counterproductive and is not recommended.
C. Children recovering from osteomyelitis should avoid strenuous activity until cleared by the healthcare provider. Premature return to physical activity can risk re-injury, delayed healing, or exacerbation of infection.
D. Osteomyelitis often requires prolonged intravenous antibiotic therapy, sometimes lasting several weeks. A home healthcare referral allows for safe administration of IV antibiotics, monitoring for complications, and ongoing patient/family education, which is an essential component of discharge planning.
Correct Answer is B
Explanation
A. There is no dietary restriction related to milk or dairy products for children with Wilms tumor. Nutritional support is important to maintain growth and healing, especially before and after surgery. This instruction is irrelevant and does not address the critical safety concern.
B. This is the priority nursing action for safety. The sign serves as a visible reminder to all staff, visitors, and caregivers to avoid any abdominal pressure or palpation. Nurses also instruct parents not to handle the child roughly or perform routine abdominal exams before surgery. This intervention significantly reduces the risk of preoperative complications and tumor spread.
C. While IM injections may cause minor bruising or bleeding, they do not increase the risk of tumor rupture. The priority concern is protecting the tumor itself, not avoiding IM injections. Injections may be given safely in other sites as necessary.
D. Venipuncture location does not affect tumor safety. Blood samples can be drawn from upper extremities without increasing the risk of rupture or metastasis. Restricting lower extremity sampling is not a standard precaution for Wilms tumor.
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