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

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

A. Apply talcum powder daily after bathing in order to prevent diaper rash. B. Use an alkaline soap to bathe the baby. C. Perform sponge baths until the baby's umbilical cord falls oﬀ. D. Ensure the bath water is at least 96 degrees Fahrenheit.

Correct Answer is C

Explanation

Sponge baths are recommended until the umbilical cord stump falls oﬀ, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath. Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin. The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.

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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?

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