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 148/74 mmHG, and respiratory rate 28 and irregular
Based on this data, which conclusion by the nurse is the most appropriate?
A) Typical for a sleeping child at this age
B) A sign of increased intracranial pressure
C) Normal for this child
D) A sign that this child has a spinal cord injury
Answer: B
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 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. Normal sleeping pulse at this age is 60-90.
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