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

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify the new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

A. Place the shoulder harnesses at the level of the infant's shoulders. B. Position the car seat at a 90° angle. C. Put a small cushion under the newborn's head for support. D. D. Keep the airbag on if the car seat is in the front seat.

Correct Answer is A

Explanation

The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.

Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.

Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.

It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.

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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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Explanation

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