A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

Pupillary changes

Disorientation

Headache

Slurred speech

Neck pain and stiffness

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason : Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes¹.

Choice B reason : Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness².

Choice C reason : Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain³.

Choice D reason : Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure².

Choice E reason : Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP⁴.

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Correct Answer is B

Explanation

Choice A reason : Chronic back pain is not a specific symptom of SLE. While individuals with SLE may experience musculoskeletal pain, it is not as characteristic as other symptoms associated with the condition.

Choice B reason : A facial rash, particularly the classic "butterfly rash" that appears across the cheeks and bridge of the nose, is one of the hallmark signs of SLE. This rash is photosensitive and can be triggered or worsened by exposure to sunlight.

Choice C reason : Thickened skin is more commonly associated with systemic sclerosis (scleroderma) than with SLE. In SLE, skin involvement can include rashes and lesions, but not typically generalized skin thickening.

Choice D reason : Nausea is not a direct symptom of SLE, although it can be a side effect of medications used to treat SLE or may occur if the gastrointestinal system is affected by the disease.

A. The catheter can become infected even with sterile precautions. B. The volume of the output solution should be greater than the input solution. C. The fluid from my abdomen will be clear or slightly yellow. D. The microwave in my kitchen can warm the solution before I use it.

Correct Answer is D

Explanation

Choice A reason : The statement is correct; even with sterile precautions, there is a risk of infection. It's important for clients to understand this risk and recognize signs of infection early¹.

Choice B reason : This statement is incorrect and indicates a misunderstanding. The volume of the output solution should be equal to or slightly less than the input solution due to fluid removal from the body¹.

Choice C reason : The fluid from the abdomen should indeed be clear or slightly yellow. Cloudy or discolored fluid can indicate an infection or other complication¹.

Choice D reason : Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution. The solution should be warmed to body temperature using a warming device designed for this purpose¹³.

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A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

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