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 C

Explanation

Timolol is a beta-blocker medication that is commonly prescribed for the treatment of glaucoma. It works by reducing the production of aqueous humor in the eye, thereby decreasing intraocular pressure. However, timolol can also be systemically absorbed, which may lead to cardiovascular side effects.

Checking the heart rate while taking timolol is important because beta-blockers can potentially lower heart rate and blood pressure. It is essential to monitor for any changes in heart rate or any other cardiovascular symptoms while using timolol eye drops.

A. Place the client in the supine position. B. Prepare to administer oxygen via Venturi face mask. C. Add a humidifier to the oxygen device. D. Encourage the client to perform deep breathing exercises. E. Examine the client's nail beds.

Correct Answer is ["C","D","E"]

Explanation

When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹. The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹. Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.

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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

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Correct Answer is C

Explanation

Correct Answer is ["C","D","E"]

Explanation

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