A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 132/58 mmHg, and respiratory rate 28 and irregular. Based on this data, which conclusion by the nurse is the most appropriate?

Question

Quizplus · Accepted Answer

A)These vital signs show a wide pulse pressure (increased systolic blood pressure and lowered diastolic blood 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 70-110. Normal blood pressure is 92-126/55-86. 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. Respiratory distress is often indicated by a respiratory rate that is lower than normal. Cardiovascular disease is a chronic condition, not an acute condition that results from trauma.
B)These vital signs show a wide pulse pressure (increased systolic blood pressure and lowered diastolic blood 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 70-110. Normal blood pressure is 92-126/55-86. 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. Respiratory distress is often indicated by a respiratory rate that is lower than normal. Cardiovascular disease is a chronic condition, not an acute condition that results from trauma.
C)These vital signs show a wide pulse pressure (increased systolic blood pressure and lowered diastolic blood 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 70-110. Normal blood pressure is 92-126/55-86. 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. Respiratory distress is often indicated by a respiratory rate that is lower than normal. Cardiovascular disease is a chronic condition, not an acute condition that results from trauma.
D)These vital signs show a wide pulse pressure (increased systolic blood pressure and lowered diastolic blood 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 70-110. Normal blood pressure is 92-126/55-86. 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. Respiratory distress is often indicated by a respiratory rate that is lower than normal. Cardiovascular disease is a chronic condition, not an acute condition that results from trauma.

A School-Age Client Loses Consciousness After Being Hit in the Head