Question

A mother arrives at the emergency department with her 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

Answer 1

The late sign of increased intracranial pressure (ICP) among the options provided is bradycardia. This is part of the Cushing's triad and indicates a severe neurological decline.

Step-by-step explanation:

In the clinical context of a child with a suspected head injury, it is essential to monitor for signs of increased intracranial pressure (ICP). While early signs of increased ICP can include symptoms such as nausea, irritability, and headache, late signs usually involve more severe neurological deficits. One such late sign of increased ICP is bradycardia, which is a slow heart rate. This occurs as part of Cushing's triad—a physiological response to increased ICP that includes hypertension, bradycardia, and irregular respirations. Other late signs of increased ICP can include a decreased level of consciousness, dilated or non-responsive pupils, decreased motor response to command, decreased sensory response to painful stimuli, abnormal posturing, and coma.