A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections.Which child should the nurse see first?
A) Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury
B) Child with brain injury who has vomited twice in 12 hours, now sleeping
C) Child with meningitis who is irritable, complaining of a "bad" headache
D) Oral temperature of 100.4°F (38°C) in a child with meningitis

Question

Quizplus · Accepted Answer

Hypertension (with widening pulse pressure),bradycardia,and changes in respiratory pattern are components of Cushing's triad,a late sign of increased intracranial pressure,indicative of impending herniation.The change in the child's blood pressure,including the widened pulse pressure (difference between systolic and diastolic pressures),is worrisome.A child with a head injury and minimal vomiting is not alarming.A child with a brain infection who is irritable with a headache needs attention,but not over the child with possible herniation.An oral temperature of 100°F would be expected in a child with a brain infection.

A Nurse Is Caring for Four Patients in the Pediatric