A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Amnesia.
Tachycardia.
Altered level of consciousness.
Hypotension.
The Correct Answer is C
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Choice A, placing the client in a private room, does not address the client’s physical needs.
Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.
Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.
Correct Answer is B
Explanation
Whether the client is a danger to herself or others. When a client is involuntarily admitted to a mental health unit, they are held for an initial period of 72 hours for evaluation and treatment. Afterward, a determination must be made as to whether or not the client is still a danger to themselves or others to keep them in the hospital.
Choices A, C, and D do not address the primary concern of ongoing safety for the client and others.
For choice A, the client's financial status or their ability to pay for prescribed medications is not relevant to their safety or need for hospitalization.
For choice C, the client's ability to make arrangements to stay with someone is important for discharge planning but not for determining their need for ongoing hospitalization.
Finally, for choice D, whether the client is unwilling to accept treatment is important, but not the sole determining factor as to whether they are a danger to themselves or others.
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