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The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?

a. Increased blood pressure
b. Bradycardia
c. Dilated pupils
d. Decreased respiratory rate

1 Answer

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Final answer:

An early sign of increased intracranial pressure (ICP) that a nurse would monitor for in a child with a head injury is dilated pupils. This sign indicates that the brain is reacting to the pressure and affecting the cranial nerves associated with eye function.

Step-by-step explanation:

The nurse plans to monitor for an early sign of increased intracranial pressure (ICP) by checking for which sign. An early sign of increased ICP can be identified by the presence of dilated pupils. Other early signs to look for include changes in consciousness, headache, nausea, and vomiting. While signs like increased blood pressure, bradycardia, and decreased respiratory rate may occur, these can be later symptoms as part of Cushing's triad and are not typically early indicators of increased ICP. Dilated pupils as an early sign indicate that the brain is starting to react to the pressure, which can affect the cranial nerves responsible for eye function.

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