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 A
Explanation
The correct answer is choice A: Toes cool to touch.
Choice A rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.
Choice B rationale: Inability to move toes is a significant concern that can also indicate nerve compression due to a tight cast. However, it may not be the first sign of a tight cast, as impaired blood circulation will likely be evident before nerve damage.
Choice C rationale: Pallor of the toes, or a pale appearance, can occur when there is restricted blood flow. However, the coolness of the toes is often noticeable before pallor develops.
Choice D rationale: Edema of the toes, or swelling, can occur due to a tight cast, but it is usually a later sign. Initially, the toes may feel cool to the touch, followed by other symptoms such as pallor, pain, and eventually, swelling.
Correct Answer is D
Explanation
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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