Main Answer:
Fixed dilated pupils, irregular respirations, and sunset eyes signal increased intracranial pressure, demanding urgent intervention for neurological compromise.A. Fixed dilated pupils C. Irregular respirations E. Sunset eyes
Therefore, the correct answer is a, c, e.
Explanation:
Late signs of increased intracranial pressure (ICP) in a child, particularly after a bike accident, include fixed dilated pupils, irregular respirations, and sunset eyes. Fixed dilated pupils indicate increased pressure on the cranial nerves, impacting the autonomic nervous system. This occurs due to the brain's compression against the skull, affecting the oculomotor nerve.
Irregular respirations are another significant sign, reflecting the brain's struggle to maintain oxygenation. As ICP rises, the brain's ability to regulate breathing becomes impaired, leading to irregular patterns. This highlights the critical nature of the situation, as inadequate oxygenation can further exacerbate brain damage.
Sunset eyes, characterized by a downward deviation of the eyes, suggest herniation of the brainstem. This occurs when the pressure within the skull becomes so elevated that the brain is forced downward, impacting the brainstem. Sunset eyes are a dire sign and indicate a severe and life-threatening increase in intracranial pressure.
In summary, recognizing fixed dilated pupils, irregular respirations, and sunset eyes is crucial for the nurse caring for a child with late signs of increased intracranial pressure. These indicators demand immediate intervention to prevent further neurological compromise.
Therefore, the correct answer is a, c, e.