A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Hypertension
Tinnitus
Hypotension
Tachycardia
The Correct Answer is A
Choice A reason: Hypertension is a manifestation of increased intracranial pressure, as it reflects the body's attempt to maintain adequate cerebral perfusion pressure (CPP) and blood flow to the brain. CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). When ICP rises, MAP must also rise to keep CPP constant and prevent cerebral ischemia. Hypertension is part of the Cushing's triad, which is a classic sign of increased ICP that also includes bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure, as it does not affect the auditory system. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors, such as ear infections, noise exposure, medications, or aging. Tinnitus may be associated with other neurological conditions, such as Meniere's disease, acoustic neuroma, or multiple sclerosis, but not with increased ICP.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure, as it indicates a decrease in MAP and CPP, which can lead to cerebral ischemia and infarction. Hypotension can be caused by various factors, such as blood loss, dehydration, shock, or medications. Hypotension may worsen the outcome of increased ICP by reducing the oxygen and nutrient delivery to the brain.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure, as it contradicts Cushing's triad. Tachycardia is an increase in heart rate that can be caused by various factors, such as anxiety, pain, fever, dehydration, or medications. Tachycardia may increase the oxygen demand and metabolic rate of the brain, which can exacerbate the effects of increased ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Asking how they are managing at home is an appropriate action by the nurse. It shows respect and interest in the client's situation and helps to assess their needs, challenges, and goals.
Choice B reason: Going automatically into the client's bedroom is not an appropriate action by the nurse. It violates the client's privacy and autonomy and may make them feel uncomfortable or threatened. The nurse should ask for permission before entering any room in the client's home.
Choice C reason: Arranging mutual future visits is an appropriate action by the nurse. It demonstrates collaboration and commitment and helps to establish a trusting relationship with the client. It also allows the nurse to plan and coordinate the care and follow-up.
Choice D reason: Thanking the client for arranging a home visit is not an appropriate action by the nurse. It implies that the home visit is a favor or a burden, rather than a professional service that the client is entitled to. It may also undermine the nurse's authority and credibility.
Choice E reason: Sitting down and discussing with the client and family members is an appropriate action by the nurse. It indicates that the nurse values the client's perspective and input, and recognizes the family as an important source of support and information. It also facilitates communication and education and promotes shared decision-making.
Correct Answer is D
Explanation
Choice A: Encourage community members to practice fire drills. This is incorrect because fire drills are a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase aims to reduce the risk and impact of disasters, while the preparedness phase aims to enhance the readiness and response capacity of individuals and communities.
Choice B: Identify community members who have disabilities. This is incorrect because identifying community members who have disabilities is also a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase focuses on actions that can prevent or minimize the occurrence or effects of disasters, such as installing smoke detectors, reinforcing buildings, or creating evacuation routes.
Choice C: Provide first aid to community members affected by a tornado. This is incorrect because providing first aid to community members affected by a tornado is a part of the response phase, not the prevention/mitigation phase. The response phase involves immediate actions to save lives, protect property, and meet basic needs after a disaster occurs.
Choice D: Assist community members in developing a disaster plan. This is correct because assisting community members in developing a disaster plan is a part of the prevention/mitigation phase. A disaster plan can help identify potential hazards, assess vulnerabilities, establish goals and objectives, and implement strategies to reduce the risk and impact of disasters.
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