A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

Pin-point pupils

Irritability

Pallor

Decreased blood pressure

Answer and Explanation

The Correct Answer is B

A. Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light

B. Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.

C. Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.

D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.

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Correct Answer is D

Explanation

a.Pancrelipase does not directly impact respiratory function. It is an enzyme replacement therapy used to aid digestion by compensating for the lack of pancreatic enzymes, not to improve lung function.

b.Cystic fibrosis affects sodium and chloride transport, leading to higher sodium levels in sweat. However, pancrelipase does not affect sodium excretion; it focuses on aiding digestion.

c.Pancrelipase helps with the digestion and absorption of fats and fat-soluble vitamins (A, D, E, K). Vitamins B and C are water-soluble and are not typically affected by the enzyme therapy used for fat digestion.

d.This is the correct answer. Pancrelipase contains enzymes (lipase, protease, and amylase) that help break down fats, proteins, and carbohydrates. In cystic fibrosis, pancreatic enzyme production is often insufficient, leading to malabsorption and steatorrhea (excessive fat in the stools). By providing the necessary enzymes, pancrelipase helps improve the digestion and absorption of dietary fats, reducing the fat content in the stools.

A. Evaluate the need for the client to remain in mitten restraints. B. Assist the client with range-of-motion exercises of the hands. C. Instruct the client's family about the purpose of mitten restraints. D. Determine the circulation status of the affected extremities every 2 hr

Correct Answer is B

Explanation

Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.

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A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is D

Explanation

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is B

Explanation

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