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
During a seizure, the child's muscles may contract forcefully, which can lead to accidental biting of the tongue or inner cheek. Inspecting the child's mouth for any signs of injury, such as bleeding or lacerations, is important for assessing and addressing immediate needs.
Instead of placing the child in a supine position (flat on their back), it is recommended to position them on their side (recovery position) to help maintain an open airway and prevent aspiration in case of vomiting or secretions. This position also helps promote drainage of saliva or other fluids from the mouth.
Seizures can be frightening for both the child and their caregivers. Providing a calm and soothing environment, offering comfort, and reassuring the child and their family can help alleviate anxiety and promote a sense of safety.
Administering medication or offering fluids should be determined based on the healthcare provider's orders and individual circumstances. It is essential to consult with the healthcare team for specific instructions regarding medications and fluid management after a seizure episode.
Correct Answer is B
Explanation
All of the listed actions can be part of evaluating the effectiveness of a performance improvement program, but identifying data collection methods is the most specific to evaluating the outcomes of the program.
Therefore, the nurse should identify data collection methods to evaluate the effectiveness of the program. Reviewing the facility's policy and procedure manual, defining the problem, and performing chart audits are all important steps in the performance improvement process, but they do not specifically address the evaluation of the program's effectiveness.
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