Author Question: Which change in vital signs should alert the nurse to increased intracranial pressure (ICP) in a ... (Read 44 times)

bcretired · **on:** Jun 27, 2018

Which change in vital signs should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

a. Rapid, shallow breathing
b. Irregular, rapid heart rate
c. Increased diastolic pressure with narrowing pulse pressure
d. Confusion and altered mental status

Question 2

Which behavior by parents or teachers will best assist the child in negotiating the developmental task of industry?

a. Identifying failures immediately and asking the child's peers for feedback
b. Structuring the environment so the child can master tasks
c. Completing homework for children who are having difficulty in completing assignments
d. Decreasing expectations to eliminate potential failures

Jayson · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhage, hemiparesis, and papilledema. Respiratory changes occur with increased intracranial pressure. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by an increasing rate and depth, then a decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with increased intracranial pressure. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

Answer to Question 2

B
The task of the caring teacher or parent is to identify areas in which a child is competent and to build on successful experiences to foster feelings of mastery and success. Structuring the environment to enhance self-confidence and to provide the opportunity to solve increasingly more complex problems will promote a sense of mastery. Asking peers for feedback reinforces the child's feelings of failure. When teachers or parents complete children's homework for them, it sends the message that you do not trust them to do a good job. Providing assistance and suggestions and praising their best efforts are more appropriate. Decreasing expectations to eliminate failures will not promote a sense of achievement or mastery.