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 B, A, C, E, D
Explanation
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
Correct Answer is C
Explanation
Choice A Reason:
Digoxin is a cardiac medication used to treat heart conditions such as heart failure and certain arrhythmias. There's no direct chemical relationship between digoxin and sulfa compounds. Generally, digoxin does not contain sulfa components, so it's less likely to cause an allergic reaction in individuals with sulfa allergies. This medication does not typically require clarification for someone with a sulfa allergy.
Choice B Reason:
Prednisone is a corticosteroid used to treat a variety of conditions, including inflammation, allergies, and autoimmune disorders. It does not contain sulfonamide groups in its structure. As a corticosteroid, prednisone is distinct from sulfonamide drugs and is generally considered safe for individuals with sulfa allergies. There is typically no need to clarify this medication for a sulfa-allergic client.
Choice C Reason:
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the sulfonamide class. While it is not the same as sulfonamide antibiotics, it contains a sulfonamide moiety in its chemical structure. There's a possibility of cross-reactivity or allergic reactions in individuals with sulfa allergies due to the structural similarity, making it essential to clarify this prescription for someone with a sulfa allergy.
Choice D Reason:
Atorvastatin is a statin medication used to lower cholesterol levels. It does not contain a sulfonamide group in its structure. Statins belong to a different drug class and do not typically pose a risk of cross-reactivity in individuals with sulfa allergies. Therefore, atorvastatin is generally considered safe and does not usually require clarification for a sulfa-allergic client.
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