The nurse is caring for a child admitted with a concussion.
Which assessment finding would be the earliest in determining the client's worsening neurological status?
The nurse is caring for a child admitted with a concussion.
Which assessment finding would be the earliest in determining the client's worsening neurological status?
A. Level of consciousness
[74%]
B. Blood pressure
[9%]
C. Intracranial pressure (ICP) measurement
[5%]
D. Pupil assessment
[11%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Neurologic
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
Analysis
Explanation
Choice A is correct. A simple observation, the level of consciousness, is widely recognized as the most sensitive indicator to a change, either improvement or deterioration, in a child's neurological status. Any changes, such as increased irritability or lethargy, should be reported to the healthcare provider.
Choice B is incorrect. Blood pressure would not be an early indicator of neurological change. Blood pressure changes occur later during neurological deterioration, specifically, systolic hypertension, which is found in increased intracranial pressure (ICP).
Choice C is incorrect. Direct ICP measurements are possible through a catheter inserted directly into the epidural space, but changes in ICP will manifest later than changes in a child's level of consciousness.
Choice D is incorrect. A pupil assessment is an essential component of a neurological exam, but changes in the pupils would be a very late sign of an issue. Alterations in the LOC would be one of the earliest signs of worsening neurological status.
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