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 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.

A. "I've been having problems with bladder control." B. "I have difficulty swallowing food." C. "I have a hard time with brushing my hair." D. "I would rather be in a wheelchair than use a walker to get around."

Correct Answer is C

Explanation

Choice A reason: While bladder control issues can significantly affect a client's quality of life, they are typically managed by a urologist or a specialist in continence, rather than an occupational therapist. Occupational therapy focuses on improving the ability to perform activities of daily living (ADLs), which generally does not include bladder control.

Choice B reason: Difficulty swallowing, known as dysphagia, can be a symptom of myasthenia gravis due to muscle weakness. Although it is a serious concern, it is usually managed with the help of a speech therapist who specializes in swallowing difficulties, rather than an occupational therapist.

Choice C reason: Having a hard time with brushing hair is directly related to the performance of ADLs, which is the primary focus of occupational therapy. An occupational therapist can assist the client by teaching energy conservation techniques, providing adaptive equipment, and modifying the task to make it easier for the client to maintain personal grooming independently.

Choice D reason: Preferring a wheelchair over a walker is a matter of mobility and personal preference. While occupational therapy can help with mobility issues, this statement alone does not indicate a need for occupational therapy unless the client has difficulty performing ADLs due to the choice of mobility aid.

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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

A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?

Correct Answer is A

Explanation

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

Correct Answer is C

Explanation

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