Clinical manifestations of increased intracranial pressure (ICP) ...

[Sportsfan2111]

Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply):
 
  a. Low-pitched cry.
  b. Sunken fontanel.
  c. Diplopia and blurred vision.
  d. Irritability.
  e. Distended scalp veins.
  f. Increased blood pressure.

Question 2

A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to:
 
  a. Place on side. c. Stabilize neck and spine.
  b. Take blood pressure. d. Check scalp and back for bleeding.

[jliusyl]

Answer to Question 1

ANS: C, D, E
Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.

Answer to Question 2

ANS: C
After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child's position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.