A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?
Tachycardia.
Hypotension.
Narrowed pulse pressure.
Increasingly severe headache.
The Correct Answer is D
The correct answer is choice d. Increasingly severe headache.
Choice A rationale:
Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.
Choice B rationale:
Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.
Choice C rationale:
Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.
Choice D rationale:
Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Absence seizures typically last for a few seconds, not 30 to 60 seconds. This choice is incorrect because it provides inaccurate information about the duration of absence seizures.
Choice B rationale:
Absence seizures are brief episodes of staring that can be mistaken for daydreaming. It is crucial for the parent to recognize this symptom to ensure the child's safety and seek appropriate medical attention if needed.
Choice C rationale:
Absence seizures usually occur without warning or an aura. There is no specific warning sign before the onset of absence seizures, making this choice incorrect.
Choice D rationale:
Absence seizures have a sudden onset and offset without any warning signs, so they do not have a gradual onset. This information is incorrect regarding absence seizures.
Correct Answer is D
Explanation
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
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