A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Nuchal rigidity
Batle's sign
Polyuria
Lethargy
The Correct Answer is D
The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal fluid. Lethargy (feeling less alert than usual) is a common symptom of increased ICP.
a. Nuchal rigidity is not a common symptom of increased ICP.
b. Batle's sign is not a common symptom of increased ICP.
c. Polyuria is not a common symptom of increased ICP.
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Related Questions
Correct Answer is C
Explanation
A.Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.
C.Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.
D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.
Correct Answer is A,B,D,C
Explanation
The correct sequence of steps the nurse should follow when a client begins to experience a tonic-clonic seizure is:
- Remain with the client and call for help.
- Place the client in the lateral position.
- Check the client for injuries.
- Reorient and reassure the client.
The nurse should first remain with the client and call for help to ensure that additional assistance is on the way. Next, the nurse should place the client in the lateral position to help keep their airway open and prevent aspiration. After the seizure has ended, the nurse should check the client for injuries that may have occurred during the seizure. Finally, the nurse should reorient and reassure the client, who may be confused or disoriented after the seizure.
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