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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Hemophilia A is a result of insufficient or absent factor VIII is correct. Hemophilia A is caused by a deficiency or absence of clotting factor VIII, which impairs the ability of blood to clot properly.

B. Von Willebrand disease is a disorder that occurs because of excess production of von Willebrand Factor is incorrect. Von Willebrand disease is actually caused by a deficiency or dysfunction of von Willebrand Factor, which is necessary for platelet adhesion and clotting.

C. Hemophilia B results from insufficient or absent factor IX is correct. Hemophilia B is caused by a deficiency of clotting factor IX, similar to hemophilia A, but involves a different clotting factor.

D. Von Willebrand disease is a disorder that occurs because of absent or insufficient von Willebrand Factor is correct. This disorder involves a deficiency or dysfunction of von Willebrand Factor, which leads to impaired clotting and easy bleeding.

E. Hemophilia A is a result of insufficient or absent fibrinogen is incorrect. Hemophilia A is caused by a deficiency of factor VIII, not fibrinogen, which is involved in the final steps of the clotting cascade.

A. Brisk pupillary reaction to light. B. Increased sleepiness C. Tachycardia D. Depressed fontanels

Correct Answer is B

Explanation

A. Brisk pupillary reaction to light is a normal finding and does not indicate increased intracranial pressure (ICP). In fact, a sluggish or non-reactive pupil response is more indicative of increased ICP.

B. Increased sleepiness or lethargy is an early sign of increased ICP in infants. The brain’s response to rising pressure can cause altered mental status, which includes drowsiness or difficulty waking.

C. Tachycardia is not typically an early sign of increased ICP. As pressure increases, the heart rate can actually slow, and bradycardia (slower heart rate) is often seen in more advanced stages.

D. Depressed fontanels are not indicative of increased ICP. In fact, in infants, increased ICP is more commonly associated with bulging fontanels, not depressed ones. Depressed fontanels could indicate dehydration or malnutrition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a family about bleeding disorders while they await the results of their child's laboratory testing. Which of the following statements accurately describes the differences in the causes of hemophilia A, hemophilia B, and von Willebrand disease? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

Correct Answer is B

Explanation

Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

The nurse is providing teaching to the parents of a school-aged child newly diagnosed with Crohn's disease about dietary measures to implement during an exacerbation. Which statement made by the parents indicates a need for further instruction?

The nurse and a new nurse (graduate nurse) are caring for a child who will require palliative care. Which statement made by the new nurse would indicate a correct understanding of palliative care?

A child with hemophilia is experiencing a bleeding episode. After applying pressure to the bleeding site, what is the priority intervention?

A nurse is caring for a 13-year-old adolescent in the pediatric emergency room who has a suspected head injury. Which of the following actions should the nurse take first?

The nurse is monitoring a 7-year-old child post-surgical resection of a supratentorial (cerebral) brain tumor. Which vital sign finding indicates Cushing's triad?

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?