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 C
Explanation
Thyrotoxicosis refers to a state of excess thyroid hormone in the body, which can occur as a result of excessive levothyroxine dosage or other causes. Nervousness is a common symptom of thyrotoxicosis, characterized by an excessive or uncontrollable feeling of anxiety or restlessness. It is important for the client to report this symptom to the healthcare provider because it may indicate an imbalance in thyroid hormone levels and may require adjustment of the medication dosage.
Polyuria, which refers to increased urination, is not a specific symptom of thyrotoxicosis. It can occur due to various factors unrelated to thyroid function.
Pruritus, or itching, is not a common symptom of thyrotoxicosis. It may be associated with other conditions or causes.
Cough is not typically associated with thyrotoxicosis. It is more commonly related to respiratory or pulmonary conditions rather than thyroid dysfunction.
Correct Answer is D
Explanation
Kosher dietary laws prohibit the consumption of shellfish (such as clam chowder and shrimp salad) and pork (such as a pulled-pork sandwich). Therefore, the nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu.
Instead, offering foods that comply with kosher guidelines, such as roasted salmon, ensures that the client's dietary needs and preferences are respected.
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