A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular
Which does the nurse suspect based on these data? 1. Spinal cord injury
2. Increased intracranial pressure.
3. Typical for sleep
4. Improvement
2
Explanation:
1. If the child suffered a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive.
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.
3. Normal sleeping pulse at this age is 60 to 90 bpm.
4. Without previous vital signs, there is no way to determine if the current changes in the vital signs indicate improvement.
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