NCLEX-RN · Question #693
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
The correct answer is D. Temperature rise to 102_F rectally. (A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood (B) Acetaminophen may be ineffective in relieving headache after head injury…
Question
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Options
- ABlood pressure increase from 100/80 to 115/85 after lunch
- BHeadache that is unresponsive to acetaminophen (Tylenol)
- CPulse rate ranges between 68 bpm and 76 bpm
- DTemperature rise to 102_F rectally
How the community answered
(29 responses)- A3% (1)
- B17% (5)
- C7% (2)
- D72% (21)
Explanation
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
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