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:
Borderline personality disorder is characterized by impulsivity, unstable relationships, and mood swings. While individuals with this disorder may have concerns about details, it is not the primary characteristic of the disorder. The impulsivity exhibited by these clients is a more prominent feature.
Choice B rationale:
While individuals with borderline personality disorder may struggle with interpersonal relationships and may sometimes display seductive behavior, this is not a defining characteristic of the disorder. The primary concern lies in their impulsivity and emotional instability.
Choice C rationale:
Clinginess can be a feature of borderline personality disorder, but it is not the defining characteristic. The disorder is more accurately characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity that begins by early adulthood and is present in various contexts.
Choice D rationale:
Borderline personality disorder is indeed marked by impulsive behavior, one of the key diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This impulsivity often leads to self-damaging behaviors, such as reckless driving, substance abuse, and unsafe sex. Including this information in the in-service is crucial for an accurate understanding of the disorder.
Correct Answer is D
Explanation
Explanation: Making funeral arrangements is an indication of hopelessness because it shows that the client has given up on the possibility of recovery or improvement. A decreased energy level, requesting a second opinion, and wanting to talk about the diagnosis are not necessarily signs of hopelessness, but rather normal reactions to a terminal illness.
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