A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Infection

Vomiting

Widening pulse pressure

Equal and reactive pupils

Intracranial pressure reading of 10 mm Hg

Answer and Explanation

Correct Answer : A,B,C

Choice A Reason:

Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.

Choice B Reason:

Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.

Choice C Reason:

Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.

Choice D Reason:

Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.

Choice E Reason:

An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.

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Correct Answer is B

Explanation

Choice A Reason:

Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.

Choice B Reason:

Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.

Choice C Reason:

Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.

Choice D Reason:

Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.

A. Stress B. Urge C. Functional D. Overflow

Correct Answer is D

Explanation

Choice A Reason:

Stress incontinence occurs when urine leaks due to pressure on the bladder from activities such as coughing, sneezing, laughing, or exercising. It is typically associated with weakened pelvic floor muscles or urethral sphincter deficiency. However, it does not usually involve a palpable bladder or frequent leakage of small amounts of urine.

Choice B Reason:

Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate followed by involuntary loss of urine. This condition is often caused by involuntary bladder contractions. While it involves frequent urination, it does not typically present with a palpable bladder.

Choice C Reason:

Functional incontinence occurs when a person is unable to reach the toilet in time due to physical or mental impairments, such as severe arthritis or dementia. This type of incontinence is not related to bladder function itself and does not involve a palpable bladder.

Choice D Reason:

Overflow incontinence is characterized by the frequent leakage of small amounts of urine due to an overfilled bladder that cannot empty completely. This condition often results in a palpable bladder upon examination, as the bladder remains distended with urine. It is commonly seen in postoperative clients or those with conditions that obstruct urine flow or impair bladder emptying.

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A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

Correct Answer is D

Explanation

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