The nurse is caring for a child admitted with head trauma after falling off of a swing. Which early assessment finding would alert the nurse to possible increased ICP in the child?

Rationale: A. Bradycardia: Bradycardia is a late sign of increased ICP and typically appears after other symptoms like changes in behavior or consciousness have developed. Early detection focuses more on neurological changes rather than vital sign alterations. B. Restlessness and confusion: These are early neurological signs indicating altered cerebral function due to increased ICP. Changes in behavior, such as irritability, restlessness, and confusion, often precede vital sign changes and are key for prompt intervention. C. Large amounts of very dilute urine: This finding suggests possible diabetes insipidus or fluid imbalance, which can occur with severe brain injury but is not an early indicator of increased ICP specifically. It is not a primary sign for monitoring ICP. D. Widened pulse pressure: Widened pulse pressure is part of Cushing’s triad, a late and serious sign of increased ICP that occurs after the brainstem is compromised. Early signs are more subtle and neurological rather than cardiovascular.