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.

Answer and Explanation

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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Correct Answer is C

Explanation

choice C, "I have heard that abusers think of themselves as important and have high self-esteem." This statement is incorrect and shows the nurse may need further education on the characteristics of an abuser. Abusers often lack self-esteem and feel powerless, using abuse as a way to gain control and confidence. Choices A, B, and D are all accurate statements and do not indicate the need for further education.

For choice A, abusers often isolate their partner to gain control over them. For choice B, abusers may lack social support and social skills, leading to violent behavior.

For choice D, abusers use intimidation tactics to maintain power in the relationship.

A. The client talks constantly about the traumatic experience. B. The client is constantly drowsy and sleeps 11-12 hr daily. C. The client reports satisfying personal relationships with family and close friends. D. The client is easily startled by loud voices.

Correct Answer is D

Explanation

The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.

Reasons why the other choices are not answers:

Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.

Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.

Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.

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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)?

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