Nokea
The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply.
- A. Stiff neck
- B. Generalized pain
- C. Glasgow Coma Scale of 15
- D. Elevated systolic blood pressure
- E. Brisk pupil response
- F. Wide pulse pressure
Correct Answer: D,F
Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.
You may also like to solve these questions
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply.
- A. Cloudy cerebral spinal fluid
- B. Pain and stiffness of the extremities
- C. Purpura of hands and feet
- D. Low white blood cell (WBC) count
- E. Low red blood cell (RBC) count
- F. Low antidiuretic hormone (ADH) levels
Correct Answer: A,C
Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
- A. Increased intracranial pressure
- B. Decreased intracranial pressure
- C. Hypervolemia
- D. Hypovolemia
Correct Answer: A
Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue.
An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?
- A. Epilepsy
- B. Trigeminal neuralgia
- C. Hypostatic pneumonia
- D. Brain tumor
Correct Answer: D
Rationale: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. The other options are not associated with papilledema or constant headache.
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
- A. Assess client's reaction to new medication schedule.
- B. Administer medications at exact intervals ordered.
- C. Document medication given and dose.
- D. Give client plenty of fluids with medications.
Correct Answer: B
Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.