The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?

Severe hypertension

Dilated and nonreactive pupils

Decreased level of consciousness

Projectile vomiting

None

Answer and Explanation

The Correct Answer is C

Choice A: Severe Hypertension

Severe hypertension can be a sign of increased intracranial pressure (ICP), but it is not typically the earliest sign. Hypertension often occurs as a compensatory mechanism to maintain cerebral perfusion pressure. While it is a significant finding, it usually follows other more immediate signs of increased ICP.

Choice B: Dilated and Nonreactive Pupils

Dilated and nonreactive pupils are a late sign of increased ICP and indicate severe brainstem compression. This finding suggests that the pressure has reached a critical level, leading to brain herniation. It is a very serious sign but not the earliest indicator of increasing ICP.

Choice C: Decreased Level of Consciousness

A decreased level of consciousness is often the earliest and most sensitive indicator of increasing ICP. Changes in consciousness can range from confusion and lethargy to complete unresponsiveness. This symptom reflects the brain’s response to increased pressure and reduced cerebral perfusion, making it a critical early sign that requires immediate attention.

Choice D: Projectile Vomiting

Projectile vomiting can occur with increased ICP due to pressure on the vomiting centers in the brainstem. However, it is not typically the earliest sign. Vomiting often accompanies other symptoms such as headache and changes in consciousness.

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Correct Answer is ["A","B","C"]

Explanation

Choice A: Observe for clear drainage.

Reason: Observing for clear drainage is important as it can indicate cerebrospinal fluid (CSF) leakage, especially after nasal or sinus surgery. CSF leakage is a serious complication that requires immediate medical attention. Clear drainage from the nose should be tested for the presence of glucose, which can confirm if it is CSF.

Choice B: Assess for signs of bleeding.

Reason: Assessing for signs of bleeding is crucial in the immediate postoperative period. Nasal packing can sometimes mask ongoing bleeding, so it is important to monitor for any signs of excessive blood loss. This includes checking for blood-soaked dressings, frequent swallowing (which can indicate blood trickling down the throat), and changes in vital signs such as increased heart rate and decreased blood pressure.

Choice C: Watch the client for frequent swallowing.

Reason: Watching the client for frequent swallowing is important because it can be a sign of posterior nasal bleeding. Blood can trickle down the back of the throat, causing the client to swallow frequently. This is a subtle but significant sign that should prompt further investigation and possible intervention.

Choice D: Change the nasal packing.

Reason: This choice is incorrect. Nasal packing should not be changed by the nurse without specific orders from the physician. Changing the packing prematurely can disrupt the surgical site, cause bleeding, and increase the risk of infection. The packing is usually removed by the surgeon or under their direct supervision.

Choice E: Administer a nasal steroid to decrease edema.

Reason: Administering a nasal steroid can help reduce inflammation and edema in the nasal passages. However, this should only be done if prescribed by the physician. Nasal steroids can help improve breathing and reduce discomfort, but they must be used according to medical guidance to avoid potential side effects.

A. Metformin B. Carvedilol C. Nitroglycerin D. Atorvastatin E. None F. None

Correct Answer is A

Explanation

Choice A: Metformin

Reason: Metformin is known to interact with contrast material, particularly iodinated contrast media, and can increase the risk of acute kidney injury (AKI). This interaction can lead to a condition known as contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury (CI-AKI). Metformin is primarily excreted by the kidneys, and impaired renal function can lead to its accumulation, increasing the risk of lactic acidosis, a rare but serious complication. Therefore, it is generally recommended to withhold metformin before and after the administration of contrast media until renal function is confirmed to be normal.

Choice B: Carvedilol

Reason: Carvedilol is a beta-blocker used to treat high blood pressure and heart failure. It does not have a known interaction with contrast media that would increase the risk of acute kidney injury. Carvedilol primarily affects the cardiovascular system and does not significantly impact renal function or interact with contrast agents.

Choice C: Nitroglycerin

Reason: Nitroglycerin is used to treat angina and other heart conditions by dilating blood vessels. It does not interact with contrast media in a way that would increase the risk of acute kidney injury. Nitroglycerin’s primary effects are on the cardiovascular system, and it does not have nephrotoxic properties.

Choice D: Atorvastatin

Reason: Atorvastatin is a statin used to lower cholesterol levels. While it can have effects on liver enzymes and muscle tissue, it does not interact with contrast media to increase the risk of acute kidney injury. Atorvastatin is metabolized by the liver and does not significantly impact renal function.

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The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?

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