A patient is admitted to the ED (emergency department) with an intracranial problem. Upon arrival the RN (registered nurse) immediately ensures that the head of the bed is elevated at 35 degrees. Identify the pathophysiological rational for this intervention?
Elevating the head of the bed promotes venous return and helps increase the ICP.
Elevation of the head of the bed aids in maintaining cerebral perfusion.
Elevation of the head of the bed will increase intracranial pressure (ICP).
The nurse should keep the head of the bed flat to ensure adequate arterial circulation.
The Correct Answer is B
A. Elevating the head of the bed promotes venous return and helps increase the ICP: This is incorrect. Elevation of the head of the bed helps to decrease intracranial pressure (ICP) by promoting venous drainage rather than increasing it.
B. Elevation of the head of the bed aids in maintaining cerebral perfusion: Elevating the head of the bed helps to decrease ICP, which in turn aids in maintaining adequate cerebral perfusion pressure.
C. Elevation of the head of the bed will increase intracranial pressure (ICP): This is incorrect. Elevation of the head of the bed is intended to reduce ICP, not increase it.
D. The nurse should keep the head of the bed flat to ensure adequate arterial circulation: This is incorrect. Keeping the head of the bed flat can increase ICP, which is counterproductive in managing intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Several episodes of black and tarry stools: This indicates melena, which is typically associated with upper gastrointestinal bleeding, not specifically Crohn's disease.
B. Several episodes of hematochezia per day: Hematochezia (fresh blood in stools) can occur in Crohn's disease due to inflammation and ulceration in the intestines.
C. Post-alcohol ingestion epigastric pain: This is more commonly associated with gastritis or peptic ulcer disease, not Crohn's disease.
D. An oral temperature of 102°F: While fever can occur in Crohn's disease during acute flare-ups, it is not a specific or definitive symptom of the condition. The primary symptoms are gastrointestinal in nature, such as abdominal pain and altered bowel habits.
Correct Answer is B
Explanation
A. Decreased respirations and CO2 retention: A thyrotoxic crisis (thyroid storm) typically involves increased, not decreased, respiratory rates and CO2 retention due to increased metabolic activity.
B. Seizures and extreme tachycardia: Thyrotoxic crisis is characterized by severe symptoms including extreme tachycardia, fever, and potentially seizures due to excessive thyroid hormone levels.
C. Constipation and a swollen abdomen: Constipation and abdominal swelling are more typical of hypothyroidism rather than a thyrotoxic crisis.
D. Hypotension and bradycardia: Thyrotoxic crisis usually causes tachycardia and hypertension rather than bradycardia and hypotension.
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