A 70-year-old patient brought in the ED by family member after falling off the ladder. His medical history includes hypertension, osteoarthritis, and type 2 diabetes mellitus. Upon nursing assessment, he has laceration on his left side of temple and bruises on left patella. His speech is slightly slurred and a weak cough reflex. Patient is alert and oriented X2 and having restlessness. Vital signs: Blood pressure 152/59, pulse 87, respirations 20. Oxygen saturation is 90% room air. He reported having slight headache and tolerable pain of 3/10 on his left knee.

The nurse is reviewing the client' assessment data to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experience. 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Increased Intracranial Pressure (ICP)

Based on the patient’s clinical presentation, which includes a fall, slurred speech, weak cough reflex, restlessness, and a slight headache, the patient is at risk for increased intracranial pressure (ICP). The history of falling from a ladder could suggest a possible head injury, and the changes in speech and restlessness could be early signs of increasing ICP. The presence of a laceration on the left temple may also indicate a traumatic brain injury, which is a key risk factor for increased ICP.

Actions to Take:

Apply oxygen via cannula at 2 L/min

Oxygen is critical for brain tissue oxygenation, especially in patients with possible head injuries and ICP. The patient's oxygen saturation is 90% on room air, which is slightly low and requires supplementation to maintain adequate oxygen levels and reduce the risk of hypoxia, which can exacerbate increased ICP.

Elevate the head of the bed to 45 degrees

Elevating the head of the bed to 30-45 degrees can help improve venous drainage from the brain, thus reducing the risk of increased ICP. Positioning the patient in this way also helps reduce pressure on the brain and enhances cerebral perfusion.

Parameters to Monitor:

Level of consciousness (LOC)

Changes in the patient's level of consciousness are a key indicator of worsening ICP. The nurse should assess the patient’s alertness, orientation, and any deterioration in cognitive function or responsiveness. The patient's current orientation level is X2, meaning they are only oriented to person and place, which may signal a developing problem.

Vital signs

Monitoring vital signs, especially blood pressure, heart rate, and respiratory rate, is crucial in assessing the patient's neurological status. Changes in blood pressure (especially widening pulse pressure) or abnormal respiratory patterns can be early indicators of increased ICP. In particular, the patient's blood pressure (152/59) suggests a possible increased risk of ICP, with the systolic value elevated but the diastolic pressure relatively low. This could be a compensatory response to ICP or another issue.

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Correct Answer is C

Explanation

A. An ICP of 10 mm HG is within normal limits.
B. An ICP of 15 mm HG is within normal limits.
C. An ICP of 20 mm Hg is elevated and should be reported immediately as it can indicate worsening conditions like brain swelling or herniation. Normal ICP is typically 5 to 15 mm Hg.
D. An ICP of 5 mm HG is also normal and would not require immediate reporting.

A. "Clouding of the lens is a manifestation of diabetic retinopathy." B. "Seeing spots is a manifestation of diabetic retinopathy." C. "It is caused by an increase in intraocular pressure." D. "Have an eye exam every 2 years."

Correct Answer is B

Explanation

A. Clouding of the lens is a sign of cataracts, not diabetic retinopathy.
B. Diabetic retinopathy is a complication of diabetes that affects the blood vessels of the retina, leading to symptoms like seeing spots, floaters, or blurred vision. It often progresses silently and can lead to blindness if not monitored.
C. Increase in intraocular pressure is a characteristic of glaucoma, not diabetic retinopathy.
D. Eye exams every 2 years is not frequent enough for diabetic patients. They should have annual eye exams to monitor for diabetic retinopathy.

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Increased Intracranial Pressure (ICP)

Actions to Take:

Parameters to Monitor:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the healthcare provider?

Correct Answer is C

Explanation

A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

Correct Answer is B

Explanation

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