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
Explanation
Choice A reason: Mitigation is not the correct level of the National Response Framework, as it refers to the actions taken to reduce or eliminate the long-term risk to human life and property from natural or man-made hazards. Mitigation activities include implementing building codes, zoning ordinances, land use planning, and flood insurance programs. Mitigation is a continuous process that occurs before, during, and after a disaster.
Choice B reason: Security is not the correct level of the National Response Framework, as it refers to the actions taken to protect the nation from threats or attacks by terrorists, criminals, or hostile states. Security activities include conducting intelligence operations, screening travelers and cargo, enforcing laws and regulations, and preventing cyberattacks. Security is a shared responsibility among federal, state, local, tribal, territorial, and private sector partners.
Choice C reason: Preparedness is the correct level of the National Response Framework, as it refers to the actions taken to plan, organize, equip, train, and exercise to build and sustain the capabilities necessary to prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk. Preparedness activities include developing emergency plans, conducting drills and exercises, educating the public, and establishing partnerships and coordination mechanisms. Preparedness is a continuous cycle of improvement that involves assessing needs, setting goals, implementing plans, and evaluating outcomes.
Choice D reason: The response phase is not the correct level of the National Response Framework, as it refers to the actions taken to save lives, protect property and the environment, stabilize the situation, and meet basic human needs in the immediate aftermath of a disaster. Response activities include activating emergency operations centers, deploying resources and personnel, providing mass care and sheltering, restoring critical infrastructure and services, and conducting search and rescue operations. Response is a short-term process that aims to restore normalcy as soon as possible.
Correct Answer is C
Explanation
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
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