A patient is intubated and placed on a mechanical ventilator. Which symptom indicates increased intracranial pressure?
Increased respirations.
Widened pulse pressure.
Prolonged capillary refill.
Decreased blood pressure.
The Correct Answer is B
Choice A rationale:
Increased respirations are not a specific symptom of increased intracranial pressure (ICP). They might occur due to other respiratory or metabolic issues.
Choice B rationale:
Widened pulse pressure (the difference between systolic and diastolic blood pressure) is a sign of increased ICP. It results from increased systolic pressure due to the body's attempt to compensate for the rising pressure within the skull.
Choice C rationale:
Prolonged capillary refill is indicative of decreased peripheral perfusion or shock, which can be caused by various factors but is not directly related to ICP.
Choice D rationale:
Decreased blood pressure is not a consistent symptom of increased ICP. In fact, widened pulse pressure is more characteristic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.
Choice B rationale:
Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.
Choice C rationale:
Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.
Choice D rationale:
Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.
Correct Answer is C
Explanation
Remove all beverages from the patient's bedside.
Choice A rationale:
Giving the patient a laxative is inappropriate and unnecessary in the context of a ruptured appendix. The focus should be on preparing the patient for surgery and managing the acute condition.
Choice B rationale:
Administering ibuprofen should be avoided as it can mask symptoms and potentially worsen the patient's condition by masking signs of inflammation or infection. This delay in appropriate care could lead to complications.
Choice C rationale:
Removing all beverages from the patient's bedside is essential. NPO (nothing by mouth) status is typically maintained for patients with suspected appendicitis or other surgical conditions to prevent potential aspiration in case surgery is required.
Choice D rationale:
Providing a heating pad is contraindicated in cases of suspected appendicitis or any acute abdominal condition. Heat can worsen inflammation and potentially cause the appendix to rupture, leading to more severe complications.
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