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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A heart rate of 60/min is within the normal range for an adult, and while it may be considered on the lower end, it is not in itself an indication to increase dopamine dosage. Dopamine is used to increase heart rate and cardiac output, but a rate of 60/min does not typically warrant an increase in dosage unless accompanied by other signs of inadequate perfusion.
Choice B reason: An oxygen saturation of 95% is within the normal range for arterial blood gases and is not an indication to increase dopamine dosage. Oxygen saturation reflects the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.
Choice C reason: A blood pressure of 90/50 mm Hg is considered low and can be an indication for increasing the dopamine dosage in a client with hypovolemic shock. Dopamine increases blood pressure by vasoconstriction and increasing cardiac output, which is critical in managing shock.
Choice D reason: A respiratory rate of 14/min is within the normal range for adults and is not an indication to increase dopamine dosage. The respiratory rate should be monitored for changes that could indicate worsening of the client's condition, but on its own, it does not dictate adjustments to dopamine therapy.
Correct Answer is D
Explanation
Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.
Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.
Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.
Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.
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