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 A
Explanation
A. A 4-year-old should typically speak in 4–5-word sentences, sing simple songs, tell imaginative stories, and identify basic colors. The behaviors described align well with normal developmental milestones for this age, indicating appropriate language, cognitive, and social development.
B. There is no indication of delay. In fact, the child is meeting expected developmental milestones. Recommending an evaluation is unnecessary and may cause unwarranted concern.
C. Imaginary friends and storytelling are common and healthy components of imaginative play at this age. They are not signs of a problem, nor are they typically linked to TV use.
D. While the child is developing well, the described skills fall within the normal range for a 4-year-old. Calling the child advanced would be inaccurate and could lead to unrealistic expectations.
Correct Answer is D
Explanation
A. Scoliosis braces, such as the thoracolumbosacral orthosis (TLSO), are most effective when worn for the prescribed duration, usually 18–23 hours per day. Removing the brace outside of approved times can reduce its effectiveness in preventing curve progression. Temporary removal due to fatigue is not recommended.
B. Most scoliosis braces need to be worn for several years or until skeletal maturity is reached, depending on the severity of the curve. Expecting only 6 months is a misconception and indicates a lack of understanding about the long-term nature of treatment.
C. Braces should not be removed for social events. Compliance is crucial for treatment success. This statement reflects misunderstanding of the importance of consistent brace use.
D. Approved brief removal of the brace for hygiene purposes is acceptable and safe. This statement demonstrates that the child understands the proper use of the brace, including that removal should be limited and purposeful, and that the brace should otherwise be worn as prescribed to manage scoliosis effectively.
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