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 C

Explanation

Choice A reason: A fractured femur, while a serious injury, does not inherently contraindicate the use of lipid emulsions. These patients may require additional nutrition if they are unable to eat adequately by mouth, and lipid emulsions can be part of their parenteral nutrition regimen if needed.

Choice B reason: Severe anorexia nervosa is a condition that can lead to malnutrition and may necessitate the use of parenteral nutrition, including lipid emulsions, to provide essential nutrients. However, care must be taken to avoid refeeding syndrome, a potentially fatal condition that can occur when malnourished patients begin to refeed too quickly.

Choice C reason: Gastrointestinal obstruction is a condition that could be exacerbated by the administration of lipid emulsions. In cases of obstruction, enteral or parenteral nutrition may need to be carefully managed or avoided until the obstruction is resolved to prevent further complications. While lipid emulsions are a valuable component of parenteral nutrition, their use must be carefully considered in the context of the patient’s overall clinical condition. In the case of gastrointestinal obstruction, the nurse would be most concerned about the prescription of a lipid emulsion due to the potential for exacerbating the obstruction and complicating the patient’s condition.

Choice D reason: Chronic diarrhea and vomiting can lead to dehydration and electrolyte imbalances, but they do not directly contraindicate the use of lipid emulsions. However, the underlying cause of these symptoms should be addressed, and fluid and electrolyte balance should be carefully monitored.

A. Hypokalemia B. Anemia C. Hypertension D. Crackles in the lungs E. Lethargy F. Proteinuria

Correct Answer is ["B","C","E","F"]

Explanation

Choice A: Hypokalemia, or low potassium levels in the blood, is not typically associated with CKD. In fact, patients with advanced CKD are more likely to experience hyperkalemia, which is an elevated potassium level, due to the kidneys’ decreased ability to excrete potassium. The normal range for serum potassium is 3.5 to 5.0 mmol/L.

Choice B: Anemia is a common finding in CKD and is due to the kidneys’ reduced production of erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. Symptoms of anemia include fatigue, weakness, and pale skin. The normal range for hemoglobin in adults is 13.8 to 17.2 grams per deciliter for men and 12.1 to 15.1 grams per deciliter for women.

Choice C: Hypertension, or high blood pressure, is both a cause and a complication of CKD. The kidneys play a crucial role in regulating blood pressure, and as their function declines, hypertension becomes more common. The normal range for blood pressure is typically considered to be 120/80 mmHg.

Choice D: Crackles in the lungs Crackles in the lungs are not a direct manifestation of CKD, but they can occur if the condition leads to fluid overload and heart failure, resulting in pulmonary edema. This is a secondary complication rather than a direct symptom of CKD.

Choice E: Lethargy and a general feeling of malaise are common in CKD due to the buildup of toxins and waste products in the blood that the kidneys can no longer effectively filter out. This can also lead to decreased mental sharpness and a reduced quality of life.

Choice F: Proteinuria, or the presence of excess protein in the urine, is a hallmark sign of CKD. It indicates damage to the kidneys’ filtering units, allowing protein that would normally be retained to leak into the urine. Persistent proteinuria is a sign of chronic kidney damage.

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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

The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?

Correct Answer is C

Explanation

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Correct Answer is ["B","C","E","F"]

Explanation

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