A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse manifestation of increased intracranial pressure? A. Fixed and dilated pupils B. Increased irritability C. Decorticate posturing D. Cheyne-Stokes respirations
The correct answer and explanation is:
The correct answer is B. Increased irritability.
Explanation:
Increased intracranial pressure (ICP) is a serious condition that can result from a head injury, such as one sustained in a motor vehicle crash. Recognizing early signs of increased ICP is crucial for timely intervention to prevent further brain damage.
Increased irritability is an early manifestation of increased ICP, especially in children. The brain swelling or pressure affects the nervous system, which can cause changes in behavior and mood. Children may become more restless, fussy, or difficult to console. This early sign is important because it often precedes more severe neurological symptoms.
Other options explained:
- A. Fixed and dilated pupils usually indicate severe brain injury or herniation. This is a late and ominous sign of increased ICP, reflecting significant brainstem involvement.
- C. Decorticate posturing is an abnormal posturing seen with severe brain injury, where the arms are flexed and legs extended. It usually occurs later in the progression of increased ICP and indicates damage to the cerebral hemispheres.
- D. Cheyne-Stokes respirations involve a pattern of gradual increase and then decrease in breathing rate followed by a temporary stop (apnea). This is a late and severe sign of brainstem dysfunction due to increased ICP.
In summary, increased irritability is an early, subtle sign that a nurse can detect, making it critical for prompt assessment and management. Recognizing these early signs helps prevent progression to more severe neurological impairments and complications.