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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hyperemesis gravidarum is a severe form of morning sickness characterized by persistent nausea, vomiting, and dehydration during pregnancy. It is important for the client to maintain proper nutrition and hydration.
Eating or drinking something every 2 to 3 hours throughout the day helps to keep the stomach relatively full, reducing the likelihood of experiencing severe nausea and vomiting due to an empty stomach. It also helps provide a steady supply of nutrients and fluids to support the client's health and the growing fetus.
Correct Answer is A
Explanation
Giving change-of-shift report to a nurse outside the client's room helps to maintain client confidentiality. By discussing sensitive client information in a private and secure area, such as a designated report room or a location where other clients or visitors cannot overhear, the nurse ensures that the client's personal and medical information is not disclosed to unauthorized individuals.
Writing a client's diagnosis on the message board in the client's room can potentially expose sensitive medical information to anyone who enters the room, including visitors or other healthcare providers who are not directly involved in the client's care.
Discussing a client's prognosis with an assistive personnel who is caring for the client may violate the principle of need-to-know confidentiality. While it is important for healthcare team members to collaborate and communicate about client care, sensitive information should only be shared on a need-to-know basis.
Discarding worksheets containing client information in a wastebasket without proper shredding or disposal methods can potentially expose client information to unauthorized individuals who may come across the discarded documents. Proper procedures for document disposal, such as shredding or using secure disposal containers, should be followed to protect client confidentiality.
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