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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Increased serum amylase is a key indicator of acute pancreatitis. Amylase is an enzyme produced by the pancreas to help digest carbohydrates. In cases of acute pancreatitis, the pancreas becomes inflamed, leading to the release of amylase into the bloodstream. Elevated levels of serum amylase, typically more than three times the upper limit of normal, are a strong indication of acute pancreatitis. This enzyme level usually rises within a few hours of the onset of pancreatitis and can remain elevated for several days.
Choice B Reason:
Increased serum calcium is not typically associated with acute pancreatitis. In fact, acute pancreatitis can often lead to hypocalcemia (low calcium levels) due to fat saponification in the pancreas, where calcium binds with fatty acids. Therefore, an increase in serum calcium would not be expected in a patient with acute pancreatitis. Monitoring calcium levels is important, but an increase is not a diagnostic marker for this condition.
Choice C Reason:
Decreased WBC (white blood cell count) is not a characteristic finding in acute pancreatitis. On the contrary, acute pancreatitis often leads to an elevated WBC count due to the inflammatory response in the body. Leukocytosis (increased WBC) is a common finding in many inflammatory and infectious conditions, including acute pancreatitis. Therefore, a decreased WBC count would not be expected and does not support the diagnosis of acute pancreatitis.
Choice D Reason:
Decreased serum lipase is incorrect. Similar to amylase, lipase is another enzyme produced by the pancreas, which helps in the digestion of fats. In acute pancreatitis, serum lipase levels also increase significantly, often more than three times the upper limit of normal. Lipase levels tend to rise slightly later than amylase but remain elevated for a longer period, making it a useful marker for diagnosing acute pancreatitis. Therefore, decreased serum lipase would not be expected in this condition.
Correct Answer is B
Explanation
Choice A reason: An increase in temperature is not a primary indicator of hypovolemic shock. While fever can occur due to infection or inflammation, it is not directly related to hypovolemic shock, which is primarily characterized by a significant loss of blood or fluids leading to decreased perfusion and oxygenation of tissues.
Choice B reason: A decrease in urinary output is a critical sign of hypovolemic shock. When the body loses a significant amount of blood or fluids, the kidneys receive less blood flow, leading to reduced urine production. This is a compensatory mechanism to conserve fluids and maintain blood pressure. Normal urine output is typically around 30 to 50 mL per hour, so a drop below this range is concerning.
Choice C reason: An increase in heart rate is a common response to hypovolemic shock as the body attempts to maintain cardiac output and blood pressure despite the loss of blood volume. Tachycardia (increased heart rate) is one of the early signs of shock, indicating that the heart is working harder to pump blood to vital organs.
Choice D reason: A decrease in respiratory rate is not typical of hypovolemic shock. In fact, hypovolemic shock often leads to an increased respiratory rate (tachypnea) as the body tries to compensate for decreased oxygen delivery to tissues. A decrease in respiratory rate could indicate other issues but is not a hallmark of hypovolemic shock.
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