Author Question: Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child ... (Read 81 times)

TVarnum · **on:** Jun 27, 2018

Which change in status 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

When caring for the adolescent hospitalized for antepartum care or for labor, delivery, and postpartum, it is important for the nurse to:

A. include the adolescent in planning her care.
B. discuss all plans with the parents before implementing them.
C. share the completed care plan with the adolescent.
D. provide the adolescent with complete physical care.

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

Answer to Question 1

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

Answer to Question 2

A
In addition to pregnancy concerns, the adolescent is also confronted by developmental tasks, including the need for autonomy and independence. By including the adolescent in develop-ment of the care plan, the nurse is treating her as an adult, allowing her some control over her care, and providing her with the opportunity to make decisions regarding her needs and pre-ferences.