Question

A 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 should assess the child frequently for which early sign of increased ICP?

a) Nausea
b) Papilledema
c) Decerebrate posturing
d) Alterations in pupil size

Answer 1

Assessing for alterations in pupil size is important to monitor for increased intracranial pressure (ICP) in a child with a head injury.

Step-by-step explanation:

The early sign of increased intracranial pressure (ICP) that the nurse should assess for in a 7-year-old child with a head injury is alterations in pupil size.

Increased ICP can affect the function of cranial nerves, including the optic nerve, which controls pupillary response. As ICP increases, the pupil may become dilated and non-reactive to light. On the other hand, as ICP decreases, the pupil may become constricted.

Assessing for alterations in pupil size can provide important information about changes in ICP and help guide appropriate interventions.