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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:Frequent exposure to low-volume noise is not typically a risk factor for hearing loss. Hearing loss is more commonly associated with prolonged exposure to high-volume noise, which can damage the delicate structures within the ear.
Choice B reason: Chronic infections of the middle ear, such as chronic otitis media, can lead to hearing loss. These infections can cause persistent inflammation and fluid buildup, which may damage the middle ear structures over time, leading to conductive hearing loss.
Choice C reason: Perforation of the eardrum, or a ruptured eardrum, can result in hearing loss. The eardrum is essential for the proper conduction of sound waves to the inner ear. A perforation disrupts this process and can reduce hearing ability until the eardrum heals or is surgically repaired.
Choice D reason: Being born with a high birth weight is not a known risk factor for hearing loss. Hearing loss at birth is more commonly associated with genetic factors, prenatal and perinatal infections, and complications during birth.
Choice E reason: The use of a loop diuretic can be a risk factor for hearing loss. These medications can have ototoxic effects, especially when administered in high doses or with rapid intravenous infusion, potentially leading to temporary or permanent hearing loss.
Correct Answer is A
Explanation
Choice A reason: Checking the pulse distal to the graft is essential to ensure that the graft is patent and that there is adequate blood flow to the distal extremity. A palpable pulse indicates that the graft is functioning properly and not occluded. The absence of a pulse could signify a serious complication, such as thrombosis or stenosis, which requires immediate attention.
Choice B reason: Keeping the left forearm below the level of the heart is not recommended as it can increase venous pressure and swelling, potentially compromising graft function. The extremity should be kept at or above heart level to promote venous return and reduce the risk of edema.
Choice C reason: Collecting blood specimens from the graft is generally avoided to prevent damage to the graft. Blood draws can be performed from other sites to protect the integrity of the graft.
Choice D reason: Splinting the left forearm is not a standard postoperative care measure for an arteriovenous graft. While protecting the graft from injury is important, immobilization with a splint is not necessary and can impede mobility and circulation.
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