A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.

Fracture of the skull

Ischemia

Hypotension

Hyperventilation

Increase in Glasgow Coma Score

Answer and Explanation

Correct Answer : B,C,D,F

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Correct Answer is A

Explanation

Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.

Identifying and treating the cause can help resolve the delirium and prevent further complications.

Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.

Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.

Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.

A. Document the time the seizure began. B. Turn the client's head to the side. C. Check the client's motor strength. D. Loosen the clothing around the client's waist.

Correct Answer is B

No explanation

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A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

Correct Answer is A

Explanation

A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

The nurse takes report on a client who was admitted with a severe heada che, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform?

A nurse is providing education to a group of older adults about the risk of stroke. Which selections made by the group indicate an understanding of the teaching? Select All that Apply (Select All that Apply.)

A client who suffered a stroke now has functional musculoskeletal deficits and is unable to perform ADLS independently. Which of the following Interventions are appropriate for this client?

A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching? Select all that apply (Select All that Apply.)