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 D

Explanation

The nurse should place a pillow under the client's head if the client is on the ﬂoor in the clonic phase of a tonic-clonic seizure. This can help protect the client's head from injury during the seizure.

Inserting a padded tongue blade into the client's mouth, keeping the client in a supine position, and gently restraining the client's extremities are not appropriate interventions for the nurse to take in this situation. Inserting a padded tongue blade into the client's mouth can cause injury to the teeth and gums. Keeping the client in a supine position can increase the risk of aspiration. Gently restraining the client's extremities can cause injury and is not recommended during a seizure.

A. Test the drainage for glucose. B. Take the client's temperature. C. Notify the charge nurse. D. Place a dressing under the client's nose.

Correct Answer is A

Explanation

The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal ﬂuid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.

b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.

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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 enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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