A parent arrives at the emergency department with a 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

1.Nausea

2.Irritability

3.Headache

4.Bradycardia

4.Bradycardia

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the primary health care provider's (PHCP's) prescriptions and would contact the PHCP to question which prescription?

1.Obtain daily weight.

2.Provide clear liquid intake.

3.Nasotracheal suction as needed.

4.Maintain a patent intravenous line.

3.Nasotracheal suction as needed.

The nurse is reviewing the record of a child with a head injury and increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

1.Flaccid paralysis of all extremities

2.Adduction of the arms at the shoulders

3.Rigid extension and pronation of the arms and legs

4.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3.Rigid extension and pronation of the arms and legs

The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority?

1.Inspecting the scalp

2.Pupillary assessment

3.Airway and breathing

4.Palpating the child's head

3.Airway and breathing

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding would the nurse expect to note on assessment of the child?

1.Not easily arousable and limited interaction

2.Loss of the ability to think clearly and rapidly

3.Loss of the ability to recognize place or person

4.Awake, alert, interacting with the environment

1.Not easily arousable and limited interaction

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What would the nurse document that the child is experiencing?

1.Decorticate posturing

1.Decerebrate posturing

3.Flexion of the arms and legs

4.Normal expected positioning after head injury

1.Decorticate posturing

The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action?

1.Document the finding.

2.Complete a head-to-toe examination.

3.Notify the primary health care provider.

4.Inform the family of the improved status.

3.Notify the primary health care provider.

The nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse would immediately test the discharge for the presence of which substance?

1.Protein

2.Glucose

3.Neutrophils

4.White blood cells

2.Glucose

The nurse is assigned to care for a child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure. Which signs would the nurse identify as indicative of this type of injury? Select all that apply.

1.Flaccid paralysis

2.Pupil response to light

3.Ipsilateral pupil dilation

4.Compression of the sixth cranial nerve

5.Shifting of the temporal lobe laterally across the tentorial notch

1.Flaccid paralysis

3.Ipsilateral pupil dilation

5.Shifting of the temporal lobe laterally across the tentorial notch

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse would modify the client's plan of care based on which interpretation of the client's change?

1.An insignificant finding

2.An improvement in condition

3.Decreasing intracranial pressure

4.Deteriorating neurological function

4.Deteriorating neurological function

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse would assess the child frequently for which early sign of increased ICP?

1.Nausea

2.Papilledema

3.Decerebrate posturing

4.Alterations in pupil size

1.Nausea

The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP would the nurse monitor?

1.Increased systolic blood pressure

2.Abnormal posturing of extremities

3.Significant widening pulse pressure

4.Changes in level of consciousness

4.Changes in level of consciousness

The nurse is reviewing the record of a child with a head injury with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Which assessment finding would the nurse expect if this type of posturing is present?

1.Flexion of the upper extremities and extension of the lower extremities.

2.Unilateral or bilateral postural change in which the extremities are rigid.

3.Abnormal extension of the upper and lower extremities with some internal rotation.

4.Arms are adducted with fists clenched, and the legs are flaccid with external rotation.

3.Abnormal extension of the upper and lower extremities with some internal rotation.

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which action would the nurse perform immediately?

1.Notify the surgeon.

2.Reinforce the dressing.

3.Document the findings and continue to monitor.

4.Circle the area of drainage and continue to monitor.

1.Notify the surgeon.

A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

1.Nausea

2.Irritability

3.Headache

4.Bradycardia

4.Bradycardia

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and would contact the pediatrician to question which prescription?

1.Obtain daily weight.

2.Provide clear liquid intake.

3.Nasotracheal suction as needed.

4.Maintain a patent intravenous line.

3.Nasotracheal suction as needed.

The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

1.Flaccid paralysis of all extremities

2.Adduction of the arms at the shoulders

3.Rigid extension and pronation of the arms and legs

4.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3.Rigid extension and pronation of the arms and legs

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which action would the nurse perform immediately?

1.Notify the surgeon.

2.Reinforce the dressing.

3.Document the findings and continue to monitor.

4.Circle the area of drainage and continue to monitor.

1.Notify the surgeon.