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 D
Explanation
Choice A rationale:
Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.
Choice B rationale:
Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.
Choice C rationale:
Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.
Choice D rationale:
Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Eating a meal prior to postural drainage is not recommended.Postural drainage uses gravity to help clear mucus from the lungs, and having a full stomach can cause discomfort and potentially lead to vomiting1.
Choice B rationale: Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas.Most people with cystic fibrosis benefit from taking pancrelipase to aid their digestion2. However, it is not specifically required prior to postural drainage.
Choice C rationale: Using an albuterol inhaler prior to postural drainage is beneficial.Albuterol is a bronchodilator that helps open the airways, making it easier to clear mucus from the lungs34. This is why it’s recommended to use prior to postural drainage.
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