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A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Slurred speech.

Bradycardia with a bounding pulse.

Confusion.

Hypertension with an increasing pulse pressure.

Nonreactive dilated pupils.

Hypotension with a decreasing pulse pressure.

Answer and Explanation

Correct Answer : B,D,E

The correct answers are b, d, and e.

Choice A: Slurred speech.

Slurred speech can be associated with increased ICP due to the pressure effects on the brain areas responsible for speech production. However, it is not typically considered a late sign of increased ICP. It may occur earlier in the progression as the brain's ability to coordinate muscle movements is affected.

Choice B: Bradycardia with a bounding pulse.

Bradycardia with a bounding pulse is a classic sign of Cushing's triad, which is a late and ominous sign of significantly increased ICP. It indicates that the body is attempting to increase arterial blood pressure to overcome the increased ICP and maintain cerebral perfusion. The normal range for adult heart rate is 60-100 beats per minute.

Choice C: Confusion.

Confusion can be an early sign of increased ICP as it can indicate changes in cerebral function. However, it is not specifically a late sign of increased ICP. Early signs of increased ICP can include headache, nausea, and confusion, as the brain is initially responding to the pressure changes.

Choice D: Hypertension with an increasing pulse pressure.

Hypertension with an increasing pulse pressure is another component of Cushing's triad. It reflects the body's compensatory mechanism to preserve cerebral blood flow in the face of rising ICP. An increasing pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP. Normal pulse pressure is typically 30-40 mm Hg.

Choice E: Nonreactive dilated pupils.

Nonreactive dilated pupils are a late sign of increased ICP and indicate pressure on the cranial nerves that control pupil size and reaction to light. This is a grave sign and often indicates impending brain herniation.

Choice F: Hypotension with a decreasing pulse pressure.

Hypotension with a decreasing pulse pressure is not typically associated with increased ICP. In fact, hypertension with a widening pulse pressure would be more indicative of increased ICP as part of Cushing's triad.

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Correct Answer is ["2600"]

Explanation

The total fluid prescribed is 5,200 mL over 24 hours. We need to calculate how much fluid the client will receive in the first 8 hours.

Step-by-Step Calculation:

Step 1: Determine how much fluid is given in the first 8 hours. The rule is that half of the total fluid is administered in the first 8 hours.

Total fluid = 5,200 mL.
Fluid for the first 8 hours = Total fluid ÷ 2.

Write it out:
5,200 ÷ 2 = 2,600.

Result: 2,600 mL.

A. Use sign language when communicating with the client. B. Speak loudly and into the client's good ear. C. Speak directly to the client in a normal, clear voice. D. Sit by the client's side and speak very slowly.

Correct Answer is C

Explanation

Choice A reason: This is incorrect because using sign language when communicating with the client is not an appropriate action for the nurse to take. Sign language is a form of communication that uses hand gestures, facial expressions, and body movements. It is not a universal language and requires training and practice. The nurse should not assume that the client knows or prefers sign language unless they have indicated so.

Choice B reason: This is incorrect because speaking loudly and into the client's good ear is not an appropriate action for the nurse to take. Speaking loudly can distort the sound quality and cause discomfort or irritation to the client. Speaking into the client's good ear can also create a sense of imbalance and isolation. The nurse should speak at a normal volume and tone, and face the client directly.

Choice C reason: This is the correct answer because speaking directly to the client in a normal, clear voice is an appropriate action for the nurse to take. Speaking directly to the client can help them see the nurse's mouth movements and facial expressions, which can enhance understanding and communication. Speaking in a normal, clear voice can help convey the message clearly and respectfully.

Choice D reason: This is incorrect because sitting by the client's side and speaking very slowly is not an appropriate action for the nurse to take. Sitting by the client's side can make it difficult for them to see the nurse's face and hear their voice. Speaking very slowly can also make the message unclear and patronizing. The nurse should sit in front of the client and speak at a normal pace.

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A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many milliliters of fluid will the client receive in the first 8 hours? Record your answer.

Correct Answer is ["2600"]

Explanation

Step-by-Step Calculation:

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Explanation

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