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 A
Explanation
The correct answer is choice a. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.
Choice B rationale:
Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.
Choice C rationale:
Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.
Choice D rationale:
Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.
Correct Answer is A
Explanation
Choice A rationale:
Lavender oil is commonly used in aromatherapy and is known for its calming effects. However, it can trigger respiratory issues in individuals with asthma. Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction, which can be exacerbated by inhaling certain substances, including strong odors and essential oils. Lavender oil, when inhaled, can potentially irritate the airways and worsen asthma symptoms. Therefore, a history of asthma is a contraindication for using lavender oil.
Choice B rationale:
Furosemide is a diuretic commonly used to treat fluid retention (edema) and hypertension. It works by increasing urine production and removing excess fluid from the body. Furosemide does not interact with lavender oil directly, and there is no known contraindication between these two substances.
Choice C rationale:
Alcohol use disorder is a condition characterized by an inability to control or stop alcohol consumption despite negative consequences. While alcohol abuse can have various health implications, it does not specifically interact with lavender oil in a way that constitutes a contraindication.
Choice D rationale:
Vitamin C is a water-soluble vitamin that plays a crucial role in various bodily functions, including immune system support and collagen synthesis. There is no evidence to suggest that taking vitamin C daily contraindicates the use of lavender oil. These two substances do not interact in a way that poses a risk to the individual.
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