A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
The client has a delayed response to verbal commands.
The client has ecchymosis around the eyes.
The client is unable to remember details of the motor-vehicle crash.
The client reports ringing in the ears.
The Correct Answer is A
Choice A Reason:
The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.
Choice B Reason:
The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.
Choice C Reason:
The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.
Choice D Reason:
The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.
Correct Answer is D
Explanation
Choice A Reason:
Age 45 years is incorrect. While age is a significant factor in osteoporosis risk, 45 years old isn't inherently considered a high-risk age for developing osteoporosis. However, bone density tends to decrease gradually with age, and after menopause in women, there's a more significant decline due to hormonal changes.
Choice B Reason:
Regular aerobic exercise is incorrect. Regular exercise, particularly weight-bearing and muscle-strengthening activities, is typically beneficial for bone health. It can help maintain or improve bone density and strength, reducing the risk of osteoporosis. Therefore, regular aerobic exercise is generally considered a protective factor against osteoporosis, rather than a risk factor.
Choice C Reason:
Uses NSAIDs for pain relief is incorrect. While long-term use of certain medications, such as glucocorticoids (steroids), can increase the risk of osteoporosis due to their impact on bone density, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief isn't directly linked to osteoporosis as a significant risk factor. However, chronic use of certain medications might have implications for bone health and should be assessed on an individual basis.
Choice D Reason:
Smoking is a known risk factor for osteoporosis. It can have detrimental effects on bone health by interfering with the body's ability to absorb calcium, decreasing estrogen levels, and impairing bone-forming cells. Consequently, smokers have a higher risk of developing osteoporosis compared to non-smokers.
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