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.
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Related Questions
Correct Answer is C
Explanation
a.Adequate fluid intake is important while taking ciprofloxacin to prevent dehydration, especially if diarrhea occurs.
b. Ciprofloxacin can disrupt the normal balance of bacteria in the gastrointestinal tract, potentially leading to diarrhea. Informing the client about this possible side effect allows them to be prepared and take appropriate measures, such as maintaining hydration and notifying their healthcare provider if diarrhea becomes severe or persistent. However, warning about sunburnis crucial as it addresses a specific side effect (photosensitivity) that clients may not be aware of, and it provides actionable advice to mitigate the risk (use of sunscreen and protective clothing).
c.Ciprofloxacin, like other fluoroquinolone antibiotics, can increase sensitivity to sunlight (photosensitivity). Clients should be advised to use sunscreen, wear protective clothing, and avoid prolonged sun exposure while taking this medication.
d.Ciprofloxacin should not be taken with antacids, calcium supplements, or dairy products because they can interfere with the absorption of the medication. It's best to take ciprofloxacin either 2 hours before or 6 hours after taking antacids or products containing calcium, magnesium, aluminum, iron, or zinc.
Correct Answer is B
Explanation
The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.
Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).
Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.
Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts
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