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 B

Explanation

Before any invasive procedure, it is essential to ensure that the client has provided informed consent. Informed consent involves providing the client with information about the procedure, its risks, benefits, and alternatives, allowing them to make an informed decision about their healthcare. The nurse should verify that the client has been adequately informed about the esophagogastroduodenoscopy procedure and has given consent before proceeding.

Informing the client about the procedure duration of 60 minutes is not a priority action. While it is helpful to provide the client with information about the procedure, the specific duration of the procedure may vary depending on various factors, and it does not require immediate attention prior to the procedure.

Ensuring that the client's bladder is full is not necessary for an esophagogastroduodenoscopy procedure. The procedure involves examining the upper gastrointestinal tract and does not involve the bladder or urinary system.

Administering an oral contrast solution is not typically required for an esophagogastroduodenoscopy procedure. Oral contrast solutions are commonly used for other

diagnostic imaging procedures, such as computed tomography (CT) scans or barium studies, but not for esophagogastroduodenoscopy.

A. Ecchymosis on the inner left thigh B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the aﬀected extremity D. Client report of muscle spasms of the left leg

Correct Answer is C

Explanation

c. Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the aﬀected extremity.

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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 caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is C

Explanation

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