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 B

Explanation

Answer: B. Cloudy dialysate outflow.

Rationale:

A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.

B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.

C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.

D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.

A. "It must be very difficult for you to see your wife in pain." B. "I wish there was more that I could do to relieve your wife's pain, too." C. "I'm sure your wife will begin to feel better soon." D. "We're doing everything we can to keep your wife comfortable."

Correct Answer is A

Explanation

Answer: A

Rationale:

A) "It must be very difficult for you to see your wife in pain.": This response acknowledges the partner's feelings and provides emotional support. It shows empathy and validates the partner's experience, helping to build rapport and trust between the nurse and the family member.

B) "I wish there was more that I could do to relieve your wife's pain, too.": While this response expresses sympathy, it might unintentionally convey a sense of helplessness or inadequacy on the part of the nurse, which could increase the partner's anxiety or frustration.

C) "I'm sure your wife will begin to feel better soon.": This response is intended to be reassuring, but it can come off as dismissive of the partner's current concern and may not address their immediate emotional needs. It also makes a promise that the nurse cannot guarantee.

D) "We're doing everything we can to keep your wife comfortable.": This response provides factual information about the care being provided, but it does not address the partner's emotional distress. It focuses on the actions of the healthcare team rather than acknowledging the partner's feelings.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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