A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Cheyne-Stokes respirations

Pupillary dilation

Altered level of consciousness

Decorticate posturing

Answer and Explanation

The Correct Answer is C

Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.

Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.

Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.

Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.

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Correct Answer is C

Explanation

Choice A reason: Irrigating the affected eye from the inner corner toward the outer corner is the recommended method for ocular irrigation. This technique helps to flush out the chemical agent without risking further contamination to the other eye or nasal passages.

Choice B reason: Positioning the client sitting up with their head turned toward the right side is appropriate when irrigating the left eye. This position allows gravity to assist in the flow of the irrigation solution away from the unaffected eye, reducing the risk of cross-contamination.

Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is a critical step in ocular irrigation after a chemical splash. It is used to measure the pH of the ocular surface to ensure that the pH has normalized to a range between 7.0 and 7.2 after irrigation, indicating that the chemical has been adequately flushed out.

Choice D reason: Using sterile water for ocular irrigation is not recommended because it can cause osmotic imbalances and damage to the corneal cells. Instead, normal saline or balanced salt solutions are preferred as they are isotonic and more compatible with the physiological environment of the eye.

A. Uric acid B. Intrinsic factor C. Chloride level D. Creatinine kinase

Correct Answer is A

Explanation

Choice A reason : Uric acid levels are expected to be increased in a client with acute gout. Gout is associated with hyperuricemia, where serum or plasma urate concentrations exceed 6.8 mg/dL. This elevation in uric acid can lead to the formation of monosodium urate crystals in joints, causing the characteristic painful inflammation of gout.

Choice B reason : Intrinsic factor is not related to gout. It is a protein produced by the stomach that is necessary for the absorption of vitamin B12.

Choice C reason : Chloride levels are typically not affected in acute gout and are not a specific indicator for this condition.

Choice D reason : Creatinine kinase is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Elevated levels may indicate muscle damage but are not a specific marker for gout.

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A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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