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
Explanation
a.While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.
b.This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
c.A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
d.Removing polyps during a colonoscopy is a common procedure and does not necessarily require a separate procedure.
Correct Answer is B
Explanation
Choice A Reason:
“Twill increase vitamin C intake by drinking orange juice." Reason why it might not indicate an understanding: Citrus juices like orange juice can exacerbate GERD symptoms due to their acidity. Increasing intake might worsen reflux symptoms for many individuals with GERD.
Choice B Reason:
“Will eat six small meals each day." This statement indicates an understanding. Eating smaller, more frequent meals instead of three large meals can help reduce pressure on the lower esophageal sphincter (LES), minimizing the likelihood of stomach contents flowing back into the esophagus, which commonly triggers GERD symptoms.
Choice C Reason:
"I will lie down for 30 minutes after each meal." Reason why it might not indicate an understanding: Lying down after meals can worsen GERD symptoms. Remaining upright or at least sitting upright for a few hours after meals helps prevent reflux by allowing gravity to assist in keeping stomach contents from moving up into the esophagus.
Choice D Reason:
“Will sleep flat on my back at night." Reason why it might not indicate an understanding: Sleeping flat on the back can aggravate GERD symptoms as it allows stomach acid to flow more easily into the esophagus. Sleeping with the head elevated (using pillows or an adjustable bed) is recommended to reduce nighttime reflux.
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