A school-age client loses consciousness after being hit in the ...

[ssal]

A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74 mmHG, and respiratory rate 28 and irregular.
 
  Based on this data, which conclusion by the nurse is the most appropriate?
  A) Typical for a sleeping child at this age
  B) A sign of increased intracranial pressure
  C) Normal for this child
  D) A sign that this child has a spinal cord injury

Question 2

The nurse is caring for a client in the neurological intensive care unit (ICU) with head trauma. The client is being monitored for increased intracranial pressure (IICP).
 
  Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate?
  A) There is nothing that can be done.
  B) Increasing brain pressure decreases the amount of blood flow to the brain itself.
  C) The pressure in the brain is increasing because the brain is shrinking.
  D) Because there is more pressure in the brain, the blood flow is also increasing.

[jliusyl]

Answer to Question 1

Answer: B

These vital signs show increased blood pressure with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. Normal heart rate for an awake child at this age is 70-110. Normal blood pressure is 92-126/55-86. Normal respirations are 20 and regular. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Normal sleeping pulse at this age is 60-90.

Answer to Question 2

Answer: B

The Monroe-Kellie hypothesis states that a dynamic equilibrium exists among the three components (brain, cerebrospinal fluid, and blood) of the skull. A change in the volume of any component risks a decrease in the remaining components to maintain normal intracranial pressures. The other statements by the nurse would be incorrect according to this hypothesis.

[ssal]

Thank you

[jliusyl]

Happy to help you