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 D

Explanation

A. "Nurses should ignore the guilt they feel when a child dies." This statement reflects an unhealthy response to grief. Nurses should acknowledge and process their feelings of guilt, rather than ignoring them, to maintain emotional well-being and provide appropriate care.

B. "The family members should be made aware that the nurse is experiencing anticipatory grief." While nurses may experience anticipatory grief, it is not appropriate to burden the family with the nurse’s own emotional experiences. Nurses should maintain professional boundaries and provide support for the family without disclosing personal grief.

C. "It is unexpected for you to be personally involved with the client and their family." This statement suggests emotional detachment, which can be counterproductive in palliative care. Nurses may form emotional connections, but they should manage their emotional responses appropriately. It’s important to balance emotional involvement with professional boundaries.

D. "Nurses should participate in grief and death education to resolve grief." This statement is correct. Nurses need education on grief and death to understand their emotional responses and help process them effectively. Education helps nurses to support their patients and families while managing their own emotions in a professional way.

A. Chest X-ray B. Urinalysis C. Complete blood count (CBC) D. Bone marrow biopsy and aspiration

Correct Answer is D

Explanation

A. Chest X-ray is not a definitive diagnostic test for leukemia. It is more commonly used to evaluate for signs of infection, lung abnormalities, or metastasis in cancer patients, but it does not confirm leukemia.

B. Urinalysis is not the definitive test for leukemia. While it may help assess kidney function or rule out other conditions, it is not used to diagnose leukemia.

C. Complete blood count (CBC) is useful for detecting abnormalities that may suggest leukemia, such as abnormal white blood cell counts, but it alone cannot definitively diagnose leukemia. It is typically part of the initial evaluation.

D. Bone marrow biopsy and aspiration is the definitive diagnostic test for leukemia. This test allows for direct examination of the bone marrow to confirm the presence of leukemia cells, making it the gold standard for diagnosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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