A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Pupillary dilation
Decorticate posturing
Altered level of consciousness
Cheyne-Stokes respirations
The Correct Answer is C
Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.
Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device
Correct Answer is A
Explanation
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
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