Answer to Question 1
C
The Nursing Interventions Classification (NIC) system is a standardized language that describes nursing interventions performed in all practice settings. NIC is a method for linking nursing interventions to diagnoses and patient outcomes. The format for each intervention includes label name, definition, list of activities that a nurse performs to carry out the intervention, and a list of background readings. NIC offers standardized language for research on nursing interventions and is a tool for determining the reimbursement for nursing services.
Answer to Question 2
2. A sign of increased intracranial pressure
Rationale:
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 70110. Normal blood pressure is 92126/5586. 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 6090.
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