A child with a head injury is at risk for increased intracranial pressure (ICP). Which change in status would alert the nurse to believe an increase in ICP has occurred?

Confusion and altered mental status

Increased diastolic pressure with narrowing pulse pressure

Irregular, rapid heartbeat

Rapid, shallow breathing

Answer and Explanation

The Correct Answer is B

A. Confusion and altered mental status can be signs of increased ICP, but these symptoms are not specific. Confusion or altered consciousness may also be observed in other conditions, so this alone may not definitively indicate increased ICP.

B. Increased diastolic pressure with narrowing pulse pressure is a classic sign of increased intracranial pressure and is a key component of Cushing's triad. This triad, which also includes bradycardia and irregular respirations, is a critical indicator of impending brain herniation and requires immediate intervention.

C. Irregular, rapid heartbeat is not a direct sign of increased ICP. While heart rate changes can occur with changes in ICP, they are usually seen as part of Cushing’s triad and would typically present with bradycardia, not rapid heartbeat.

D. Rapid, shallow breathing can occur in response to other conditions, but it is not the most specific or early sign of increased ICP. Changes in the respiratory pattern with increased ICP often involve more distinct alterations like Cheyne-Stokes or irregular breathing patterns.

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Correct Answer is B

Explanation

A. Palliative care serves to hasten death and make the process easier for the family is an incorrect statement. Palliative care is focused on providing relief from symptoms and improving the quality of life, not hastening death.

B. Palliative care provides pain and symptom management and best quality of life for the child is the correct understanding of palliative care. It focuses on managing symptoms and providing support to improve quality of life, regardless of the child’s age or stage of illness.

C. The goal of palliative care is to place the child in a hospice setting at the end of life is not entirely correct. Palliative care can be provided at any stage of a serious illness, not just at the end of life, and it does not automatically mean placement in hospice.

D. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals is a supportive role, but it does not fully define the scope of palliative care, which is focused on symptom management and improving quality of life.

A. Urine specific gravity 1.015 B. Respiratory rate 24/min C. Heart rate 130/min D. Capillary refill greater than 3 seconds

Correct Answer is A

Explanation

A. Urine specific gravity 1.015 is correct. A specific gravity of 1.015 indicates good hydration status and that the child is effectively retaining fluids after oral rehydration therapy. Normal urine specific gravity ranges from 1.010 to 1.020.

B. Respiratory rate 24/min is not directly related to hydration status and does not necessarily indicate that rehydration therapy has been effective. It is a normal rate for a 3-year-old child, but respiratory rate alone isn't an indicator of fluid balance.

C. Heart rate 130/min is elevated for a 3-year-old child and may indicate dehydration or other stressors, suggesting that oral rehydration therapy has not been completely effective. A normal heart rate for this age is typically 80-120 beats per minute.

D. Capillary refill greater than 3 seconds is a sign of dehydration and poor perfusion, indicating that the oral rehydration therapy has not been effective in restoring hydration. Normal capillary refill time is less than 2 seconds.

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A child with a head injury is at risk for increased intracranial pressure (ICP). Which change in status would alert the nurse to believe an increase in ICP has occurred?

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