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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A nurse discussing comorbidities associated with eating disorders with a newly licensed nurse should include depression, anxiety, and obsessive-compulsive disorder (OCD) in the discussion. Clients who have eating disorders often have comorbid psychiatric conditions.
Depression and anxiety are two common conditions among clients with eating disorders. OCD is another condition that is often associated with eating disorders. Clients with OCD may have obsessive thoughts about food intake, weight, and body image. These clients may also engage in compulsive behaviors related to eating, such as calorie counting or food restriction. Options C and E are incorrect because breathing-related sleep disorders and schizophrenia are not typically associated with eating disorders.
Correct Answer is B
Explanation
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
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