A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Tachypnea

Hypotension

Decreased level of consciousness

Bilateral weakness of extremities

Answer and Explanation

The Correct Answer is C

Choice A: Tachypnea Tachypnea, or rapid breathing, is not typically a direct sign of increased ICP. While it can be associated with various medical conditions, it is not specifically indicative of increased ICP. However, it’s important to note that breathing patterns can change with advanced ICP changes, but these are usually characterized by irregularities rather than just increased rate. Increased intracranial pressure (ICP) is a critical condition that can occur after a traumatic brain injury (TBI). It results from the brain tissue’s response to injury, leading to swelling or bleeding within the skull. The skull is a rigid structure, so any increase in content, such as blood or edema, can lead to an increase in pressure.

Choice B: Hypotension Hypotension, or low blood pressure, is generally not associated with increased ICP. In fact, one of the signs of increased ICP is Cushing’s triad, which includes hypertension (high blood pressure), bradycardia (slow heart rate), and irregular respirations. Therefore, hypotension would not be a typical manifestation of increased ICP.

Choice C: Decreased level of consciousness A decreased level of consciousness is a hallmark sign of increased ICP. As pressure within the skull increases, it can lead to compression of the brain tissue and disruption of cerebral blood flow. This can manifest as changes in alertness, drowsiness, confusion, and in severe cases, loss of consciousness1. when monitoring a client who has sustained a TBI, the nurse should be vigilant for signs of increased ICP, with a decreased level of consciousness being a primary indicator. Other signs may include headache, nausea, vomiting, and changes in pupil size or reactivity. It is crucial to identify and treat increased ICP promptly to prevent further brain injury and potential long-term consequences.

Choice D: Bilateral weakness of extremities While bilateral weakness can be a sign of neurological damage, it is not specific to increased ICP. Increased ICP is more likely to cause global effects on consciousness and brain function rather than isolated weakness in limbs unless there is focal brain injury causing raised ICP.

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Correct Answer is B

Explanation

Choice A reason: A BUN level of 8 mg/dL and creatinine level of 0.7 mg/dL are within normal ranges and would not be expected in a client with CKD².

Choice B reason: Elevated BUN and creatinine levels, such as 45 mg/dL and 8 mg/dL respectively, are indicative of impaired kidney function, which is consistent with CKD².

Choice C reason: A BUN level of 10 mg/dL and creatinine level of 0.3 mg/dL are lower than the expected values for a client with CKD, indicating better kidney function than typically seen in CKD².

Choice D reason: A BUN level of 23 mg/dL and creatinine level of 1.0 mg/dL may be slightly elevated but are not as indicative of CKD as the values in choice B².

A. "A headache is an indication of an allergy to the medication." B. "A headache is an expected adverse effect of the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache indicates tolerance to the medication."

Correct Answer is B

Explanation

Choice A reason:

A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions are more likely to present with symptoms such as rash, itching, or difficulty breathing.

Choice B reason:Headaches are a well-known side effect of nitroglycerin, due to its vasodilating effects, which can cause dilation of cerebral arteries.

Choice C reason:While anxiety can cause headaches, in this context, where the client has taken nitroglycerin, it is more likely that the headache is a side effect of the medication rather than anxiety.

Choice D reason:Tolerance to medication would reduce the effectiveness of the drug, not typically cause a headache. The headache is a common side effect, not an indication of tolerance.

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A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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