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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement demonstrates an understanding of the concept of spacing out immunizations to reduce the number of shots given during a single visit. By making multiple office visits, the parent can ensure that their child receives the recommended immunizations while minimizing the number of injections at each visit.
Lactose intolerance is not a contraindication to receiving immunizations. Most vaccines do not contain lactose, and even if they do, the amount present is typically minimal and not expected to cause an adverse reaction in individuals with lactose intolerance.
The first flu immunization is typically recommended for children starting at 6 months of age, not at 6 years of age.
The human papillomavirus (HPV) vaccine is typically recommended for preteens and adolescents, usually starting between the ages of 11 and 12. It is not typically administered when a child enters kindergarten.
Correct Answer is A
Explanation
a. Support the client's decision to stop the treatment.
As a nurse, it is important to respect the client's autonomy and right to make decisions about their own care. The decision to stop dialysis treatment is a personal one and should be respected by the healthcare team. The nurse should support the client's decision and provide information and resources to help the client manage symptoms and maintain comfort during the end-of-life process.
It is not appropriate for the nurse to suggest that the client discuss the decision with her family or to discuss alternative treatment methods, as these decisions should be made by the client in conjunction with their healthcare provider.
It may be appropriate to offer spiritual or emotional support to the client, but this should be based on the client's preferences and not imposed upon them by the healthcare team.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today