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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Depression commonly coexists with eating disorders. Patients with eating disorders often experience profound sadness, hopelessness, and a distorted body image, leading to depressive symptoms. Addressing both conditions simultaneously is crucial for effective treatment.

Choice B rationale:

Obsessive-compulsive disorder (OCD) frequently accompanies eating disorders. Obsessive thoughts about body weight, shape, and food intake are common in individuals with eating disorders. These obsessions can lead to compulsive behaviors, such as strict dietary rules or excessive exercise, reinforcing the connection between eating disorders and OCD.

Choice C rationale:

Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves distorted thinking, hallucinations, and impaired emotional responses, which are distinct from the symptoms of eating disorders. While it's essential to assess patients comprehensively, schizophrenia is not a common comorbidity of eating disorders.

Choice D rationale:

Breathing-related sleep disorder is not a direct comorbidity of eating disorders. However, individuals with severe eating disorders, especially anorexia nervosa, may experience complications like sleep apnea due to extreme weight loss. While this is a potential issue, it is not a direct comorbidity of eating disorders for all patients.

Choice E rationale:

Anxiety often coexists with eating disorders. Anxiety about body weight, shape, and food intake is a significant concern for individuals with eating disorders. This anxiety can further perpetuate disordered eating behaviors, creating a cycle that is challenging to break without addressing the underlying anxiety.

A. Perform exercises prior to bedtime. B. Take a 1-hr nap during the day. C. Eat a light snack before bedtime. D. Stay in bed at least 1 hr if unable to fall asleep.

Correct Answer is C

Explanation

C) Eat a light snack before bedtime.

The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.

The other options are not recommended for promoting nighttime sleep:

A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.

B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.

D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.

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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?

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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?