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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Bubbling in the water seal chamber with exhalation can be a normal finding as it indicates that air is being evacuated from the pleural space. However, continuous bubbling may suggest an air leak, which should be evaluated.
Choice B reason : The visibility of the eyelets is not typically a concern unless the tube is dislodged. If the chest tube is functioning properly and the eyelets are meant to be within the chest cavity, their visibility might indicate dislodgement.
Choice C reason : Crepitus, or subcutaneous emphysema, can occur if air leaks into the tissue surrounding the insertion site. This can be a sign of a problem with the chest tube placement or function and should be reported to the provider immediately.
Choice D reason : Movement of the trachea toward the unaffected side, or tracheal deviation, can be a sign of tension pneumothorax, a life-threatening condition that requires immediate attention.
Correct Answer is A
Explanation
Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.
Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.
Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.
Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.
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