A nurse is assessing a 1-year-old child for increased intracranial pressure (ICP). Which sign should the nurse assess for with this age of child?
a. Headache
b. Bulging fontanel
c. Tachypnea
d. Increase in head circumference
A
Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. A bulging fontanel is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.
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