Author Question: The nurse is caring for a child who has sustained a head injury in an automobile accident and is ... (Read 44 times)

123654777 · **on:** Jul 22, 2018

The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for:

1. Apnea
2. Posturing
3. Tachycardia
4. Changes in level of consciousness (LOC)

Question 2

The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, I haven't had an appetite at all for the last few weeks. Which of the following responses by the nurse would be best?

1. The last few weeks?
2. You haven't had an appetite at all?
3. When the medication begins to work, you will begin to feel better.
4. Think about everything that you have been through. It will take time for your appetite to improve.

Mollythedog · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4

Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of in-creased ICP include tachycardia, leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

Answer to Question 2

2

Rationale: The therapeutic communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. When the medication begins to work, you will begin to feel better. and Think about everything that you have been through. It will take time for your appetite to improve. block the communication process. The last few weeks? focuses on the number of weeks that the lack of appetite has been present, rather than the specific problem.