A child with a known neuroblastoma begins vomiting uncontrollably. The nurse assesses the child's _____ for signs of increased intracranial pressure
1. Pupils and hand grasps
2. Intake and output
3. Respiratory rate
4. Verbal responses
1
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1. Sluggish and dilated pupils along with weakened hand grasps are an indication of increased ICP.
2. Intake and output are not a concern at this time.
3. The child's respiratory rate should be assessed, but it is not the priority at this time.
4. Verbal responses can be assessed, but it is not the priority at this time.
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