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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The absolute neutrophil count (ANC) is the best indicator of a child's ability to fight infection. Neutrophils are a type of white blood cell crucial for fighting bacterial infections, and chemotherapy can suppress bone marrow production of neutrophils. The ANC helps assess the risk for infection and the need for additional precautions, such as infection control.
B. Eosinophils are a type of white blood cell that primarily respond to allergies and parasitic infections, and their count is not used to assess infection risk in chemotherapy patients.
C. The red blood cell count (RBC) is important for assessing oxygen-carrying capacity but does not directly relate to infection-fighting ability.
D. Hemoglobin (Hgb) reflects the oxygen-carrying capacity of the blood, not the body's ability to fight infection.
Correct Answer is C
Explanation
A. 2-3 months is too early for palatoplasty, as the child’s palate and facial structures need time to develop. Surgical repair of the palate is typically done later, once the child is more developed.
B. 18-24 months is too late for the initial palatoplasty. Early intervention is preferred for speech development and other aspects of the child’s overall growth.
C. 6-12 months is the recommended age range for palatoplasty, as this is the time when the child’s palate has matured enough for surgery, and earlier intervention supports optimal outcomes for speech and facial development.
D. 4-5 years is too late for the first palatoplasty. However, additional surgeries or interventions may be needed during this age range as the child grows and their oral structures continue to develop.
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