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 D
Explanation
Choice A Reason:
"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is considered beneficial for heart health and reducing the risk of stroke.
Choice B Reason:
"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control, which usually reduces the risk of stroke. A higher HbA1c level is associated with an increased risk of complications in diabetes, including stroke.
Choice C Reason:
"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with diabetes. These medications may have various uses but are not a standard preventive measure for stroke in this context.
Choice D Reason:
"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate. Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially for individuals with diabetes. Weight management contributes to better control of blood pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.
Correct Answer is B
Explanation
Choice A Reason:
LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not specifically monitored in relation to warfarin therapy.
Choice B Reason:
INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication, and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the clotting tendency of the blood and ensures that the dosage of warfarin is within the therapeutic range to prevent blood clots without causing excessive bleeding.
Choice C Reason:
BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney function and is not directly related to monitoring warfarin therapy.
Choice D Reason:
Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood and is not directly related to monitoring warfarin therapy for atrial fibrillation.
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