An 18-month-old child is admitted with signs of increased ...

[rachel9]

An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient?
 
  A) Numbness of fingers and decreased temperature
  B) Increased pulse rate and decreased blood pressure
  C) Increased temperature and decreased respiratory rate
  D) Decreased level of consciousness and increased respiratory rate

Question 2

The nurse is planning care for a preschool-age child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this patient's musculoskeletal status?
 
  A) Risk for self-care deficit related to impaired mobility
  B) Risk for disuse syndrome related to spasticity of muscle groups
  C) Impaired verbal communication related to neurologic impairment
  D) Risk for delayed growth and development related to activity restriction

[samiel-sayed]

Answer to Question 1

C
Feedback:
Manifestations of increased intracranial pressure include increased body temperature and decreased respiratory rate. Pulse rate slows, and the blood pressure increases.

Answer to Question 2

B
Feedback:
Children with cerebral palsy need promotion of any function that is not already impaired to prevent further loss of function and allow them to master the highest level of self-care. Learning to be ambulatory is an important part of self-care because it pays a large role in determining how independent the child can become. Walking can be difficult for the child to master because of lack of muscle coordination. Preventing contractures is also important to maintain motor function. Risk for self-care deficit focuses on self-care measures such as dressing, toothbrushing, bathing, and toileting, so the child can not only gain self-esteem by accomplishing these tasks but also achieve optimal independence. Impaired verbal communication addresses focuses on speech and not necessary the entire musculoskeletal status. The risk for delayed growth and development focuses on the child's potential inability to pursue stimulating activities and surroundings because of not being fully mobile.