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

Quizplus · Accepted Answer

The child with a head injury may have confusion and altered mental status,a change in vital signs,retinal hemorrhaging,hemiparesis,and papilledema.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.Temperature elevation may occur in children with ICP.Changes in blood pressure occur,but the diastolic pressure does not increase,nor is there a narrowing of pulse pressure.

Which Change in Status Should Alert the Nurse to Increased