A seven-year-old with a head injury is hospitalized after losing consciousness when he was 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, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury.
2. A sign of increased intracranial pressure.
3. Typical for a sleeping child at this age.
4. A sign that the child's condition is improving.
2
Rationale 1: 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.
Rationale 2: These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure.
Rationale 3: Normal sleeping pulse at this age is 60-90 bpm.
Rationale 4: Without previous vital signs, there is no way to determine the changes in the vital signs.
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