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 J
Explanation
Choice A Reason:
Gaining weight can be an indicator of improved nutrition, but it does not directly address the client’s ability to swallow safely and effectively. Weight gain could be due to other factors such as fluid retention or changes in metabolism. Therefore, while it is a positive outcome, it is not the best indicator of improved swallowing function.
Choice B Reason:
Choosing preferred items from the menu indicates that the client is engaged in their meal planning and has an appetite. However, it does not directly measure the client’s ability to swallow safely. The client might still have difficulty swallowing even if they are choosing their preferred foods.
Choice C Reason:
Clear understanding and articulation are important for communication and can indicate cognitive improvement. However, this choice does not directly relate to the client’s swallowing ability. The primary concern in this scenario is the client’s ability to swallow safely, not their communication skills.
Choice D Reason:
Eating 75 to 100% of all meals and snacks is the best indicator that the client has improved their swallowing ability. This choice directly measures the client’s ability to consume food and liquids safely and effectively. It shows that the client can manage their meals without significant difficulty, which is the primary goal of the intervention.
Correct Answer is A
Explanation
Choice A Reason:
Constant bubbling in the water seal chamber of a chest drainage system typically indicates an air leak. This can occur if there is a break in the system, allowing air to enter. The air leak could be from the chest tube insertion site, the tubing, or the drainage system itself. Identifying and correcting the source of the air leak is crucial to ensure the system functions properly and the patient’s condition does not worsen.
Choice B Reason:
A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, leading to increased pressure on the lungs and other thoracic structures. While a tension pneumothorax can cause significant respiratory distress, it is not typically indicated by constant bubbling in the water seal chamber. Instead, signs of tension pneumothorax include tracheal deviation, hypotension, and severe respiratory distress.
Choice C Reason:
A kink in the tubing of a chest drainage system can obstruct the flow of air and fluid, but it does not cause constant bubbling in the water seal chamber. Instead, a kink would likely result in a lack of drainage or intermittent bubbling as the obstruction temporarily blocks and then allows passage of air or fluid.
Choice D Reason:
Increased drainage in a chest tube system indicates that more fluid or air is being removed from the pleural space, but it does not cause constant bubbling in the water seal chamber. Increased drainage might be seen in cases of hemothorax or pleural effusion, where large amounts of fluid are present.
Choice E Reason:
Tidaling refers to the normal rise and fall of water in the water seal chamber with the patient’s respiratory cycle. It indicates that the chest tube is patent and functioning correctly. Absence of tidaling could suggest that the lung has fully re-expanded or that there is an obstruction in the system. However, tidaling itself does not cause constant bubbling.
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