A school nurse is assessing a child who fell from playground equipment and landed head-first. Which of the following manifestations should the nurse recognize as indicating the presence of increased intracranial pressure?
Report of diplopia
Hyperactivity
Nuchal rigidity
Report of sore throat
The Correct Answer is A
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
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Related Questions
Correct Answer is C
Explanation
A. "What is your pain level right now?": This response doesn't directly address the child's question about mortality and may deflect the conversation away from the child's concerns. While assessing pain is important, it should not be the immediate response to a question about mortality.
B. "Your doctor will be able to answer your questions tomorrow.": This response delays addressing the child's concerns and may leave the child feeling anxious or unsupported in the meantime. It's important for the nurse to provide immediate support and reassurance when a child expresses fears or worries.
C. "It sounds like you are worried. Tell me what you have been told.": This response acknowledges the child's emotions and invites them to share their thoughts and concerns. It opens up a dialogue between the nurse and the child, allowing the nurse to provide appropriate support and information based on the child's understanding and perspective.
D. "It's natural to worry about death, but you should focus your energy on getting better.": While this response acknowledges the child's worry, it may come across as dismissive or minimizing of the child's concerns about mortality. It's important to validate the child's emotions and offer support rather than redirecting their focus away from their worries.
Correct Answer is C
Explanation
A. Weight gain:
Weight gain is not typically associated with vasoocclusive crisis in sickle cell anemia. In fact, individuals may experience dehydration and weight loss due to increased metabolic demands during a crisis.
B. Bradypnea:
Bradypnea, or slow breathing, is not a characteristic feature of vasoocclusive crisis in sickle cell anemia. Respiratory rate may be normal or increased due to pain or compensatory mechanisms.
C. Pain:
This is the correct option. Pain is the hallmark manifestation of vasoocclusive crisis in sickle cell anemia. The pain can occur anywhere in the body but most commonly affects the bones, joints, abdomen, and chest. The severity of pain can vary from mild to severe and may require hospitalization for pain management.
D. Diarrhea:
Diarrhea is not typically associated with vasoocclusive crisis in sickle cell anemia. Gastrointestinal symptoms such as abdominal pain and nausea may occur, but diarrhea is not a common manifestation of vasoocclusive crisis.
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