A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Papilledema

Restlessness

Projectile vomiting

Decorticate posturing

Answer and Explanation

The Correct Answer is B

Choice A reason: Papilledema, which is the swelling of the optic disc due to increased ICP, is not typically an early sign. It is usually a later manifestation because it takes time for the pressure to build up and affect the optic nerve.

Choice B reason: Restlessness can be an early sign of increased ICP. As ICP begins to rise, it can cause subtle changes in a person's level of consciousness, leading to agitation or restlessness. This is often one of the first signs that healthcare providers notice when monitoring for changes in neurological status.

Choice C reason: Projectile vomiting may occur with increased ICP, but it is not usually an early sign. It tends to occur after other symptoms such as headache and altered consciousness and is more indicative of significant pressure increases that affect the brainstem.

Choice D reason: Decorticate posturing is a severe sign of brain injury associated with increased ICP but is not an early sign. It indicates significant damage to the brain and is a late and ominous sign in the progression of increased ICP.

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Correct Answer is C

Explanation

Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is not recommended. The preferred sites for subcutaneous injections are the fatty tissue over the triceps, the abdomen from below the costal margin to the iliac crests, and the anterior aspects of the thighs. The area above the iliac crest may not have sufficient subcutaneous tissue, which could affect the absorption of the medication.

Choice B reason: Using a 1-inch needle can be appropriate depending on the client's body mass. For most adults, a 5/8-inch to 1-inch needle is recommended for subcutaneous injections to ensure the medication is delivered to the subcutaneous tissue and not into the muscle.

Choice C reason: Using a 25-gauge needle is the appropriate action when administering heparin subcutaneously. A smaller gauge needle, such as 25-gauge, is typically used for subcutaneous injections to minimize discomfort and tissue trauma.

Choice D reason: Massaging the injection site after administration of the medication is not recommended when administering heparin subcutaneously. Massaging the site can cause the medication to be absorbed more quickly than intended and may increase the risk of bleeding.

A. Administer prescribed corticosteroids. B. Slow infusion rate and contact the provider. C. Lower the head of the bed to semi-Fowler's. D. Change infusion to lactated Ringer's and maintain rate.

Correct Answer is B

Explanation

Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.

Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.

Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.

Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.

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A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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