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 A

Explanation

A. Administering anti-seizure medication is the priority. In a child experiencing status epilepticus, immediate administration of anti-seizure medication is essential to stop the seizure activity and prevent further neurological damage. The primary goal is to terminate the seizure as quickly as possible.

B. Restraining the child to prevent injury is not the priority. Restraining a child during a seizure can increase the risk of injury and is not recommended. Instead, protecting the child from harm by placing them in a safe position is more appropriate.

C. Providing emotional support to the child's family is important, but it is not the immediate priority during the acute phase of status epilepticus. The child's immediate safety and health take precedence.

D. Documenting the seizure activity should be done after ensuring that the seizure has been controlled. Accurate documentation is important, but it is secondary to the intervention needed to stop the seizure.

A. Respiratory rate B. Blood pressure C. Body weight D. Skin integrity

Correct Answer is C

Explanation

A. Respiratory rate can be influenced by many factors, including fever or anxiety, and is not the most reliable indicator of fluid loss.

B. Blood pressure may change with severe dehydration, but it can be a late sign, and other factors (like shock) can also affect blood pressure, so it's not the most reliable early indicator.

C. Body weight is the most reliable and sensitive indicator of fluid loss, as even small changes in weight reflect changes in hydration status. Monitoring weight helps assess fluid loss accurately.

D. Skin integrity can be affected by dehydration, but it's not the most reliable indicator of fluid loss. It may take longer to show visible signs such as dry skin or poor turgor.

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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

During an episode of status epilepticus of a hospitalized child, what is the priority intervention?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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