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 ["C","D"]
Explanation
Choice A reason: The inability to take risks is not a quality of an effective nurse leader, as it may limit the leader's potential for growth, innovation, and improvement. Effective nurse leaders are willing to take calculated risks that are based on evidence, experience, and intuition. They are also able to learn from their mistakes and failures and use them as opportunities for development.
Choice B reason: Never consider being a follower is not a quality of an effective nurse leader, as it may indicate a lack of flexibility, collaboration, and respect for others. Effective nurse leaders are able to adapt to different situations and roles, depending on the needs and goals of the team. They are also able to recognize the strengths and contributions of their followers and empower them to achieve their full potential.
Choice C reason: The ability to set priorities is a quality of an effective nurse leader, as it helps the leader to focus on the most important and urgent tasks and goals. Effective nurse leaders are able to identify the needs and expectations of their clients, staff, and organization, and allocate their time, resources, and energy accordingly. They are also able to delegate tasks appropriately and efficiently.
Choice D reason: Integrity is a quality of an effective nurse leader, as it reflects the leader's honesty, trustworthiness, and ethical standards. Effective nurse leaders are able to act in accordance with their values and principles, and uphold the professional code of conduct. They are also able to communicate openly and transparently, and accept responsibility and accountability for their actions and decisions.
Choice E reason: Critical care certification is not a quality of an effective nurse leader, as it is not a requirement or a guarantee for leadership success. Critical care certification is a credential that demonstrates the nurse's knowledge and competence in providing care to critically ill patients. While it may enhance the nurse's clinical skills and confidence, it does not necessarily reflect the nurse's leadership skills or abilities. Effective nurse leaders can come from various backgrounds and specialties, as long as they have the necessary qualities and attributes that enable them to lead others effectively.
Correct Answer is C
Explanation
Choice A reason: Delivering a urine specimen to the laboratory is not a priority task, as it does not affect the client's immediate health or safety. This task can be done later or delegated to another staff member.
Choice B reason: Feeding a client who has bilateral casts is an important task, as it helps the client meet their nutritional needs and prevents complications such as pressure ulcers. However, this task is not as urgent as monitoring blood glucose levels, as it can be done within a reasonable time frame without causing harm to the client.
Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin is a priority task, as it determines the dosage of insulin that the client needs to receive. Insulin is a high-alert medication that can cause serious adverse effects if given incorrectly. Therefore, this task should be done first by the AP who has been trained and certified to do so.
Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is a low-priority task, as it does not affect the client's physical or psychological well-being. This task can be done at any time or delegated to another staff member.
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