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