A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Peripheral edema

Diarrhea

Decreased pedal pulses

Hypertension

Answer and Explanation

The Correct Answer is D

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.

c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

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Correct Answer is A

Explanation

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

A. "Russell's traction uses a sling under the knee to treat a fracture of the femur." B. "Russell's traction uses a cervical halter to decrease cervical muscle spasms." C. "Russell's traction uses skeletal pins to stabilize the fracture." D. "Russell's traction uses a pelvic girdle belt to decrease lower back pain."

Correct Answer is A

Explanation

The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the aﬀected leg to provide continuous traction.

Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.

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A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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