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 : In multiple myeloma, the white blood cell count (WBC) is not typically elevated. Multiple myeloma primarily affects plasma cells, a type of white blood cell, but it does not usually result in an increased WBC count. Instead, the disease is characterized by the presence of abnormal plasma cells in the bone marrow, which can crowd out healthy blood cells¹.

Choice B reason : Patients with multiple myeloma often have elevated calcium levels, a condition known as hypercalcemia. This occurs because the cancerous plasma cells produce substances that cause bones to break down at a rate faster than they are made, releasing calcium into the bloodstream. Symptoms of hypercalcemia can include fatigue, weakness, confusion, and increased thirst and urination¹².

Choice C reason : The absolute neutrophil count (ANC) is not typically increased in multiple myeloma. ANC is a measure of the number of neutrophils, a type of white blood cell important for fighting infections. While multiple myeloma can affect overall bone marrow function, it does not specifically cause an increase in ANC.

Choice D reason : Platelet counts are not typically elevated in multiple myeloma. In fact, patients may experience thrombocytopenia, or a low platelet count, due to the overproduction of abnormal plasma cells in the bone marrow, which can interfere with the production of platelets¹.

A. Chronic back pain B. Facial rash C. Thickened skin D. Nausea

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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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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