The LPN/LVN is assisting the RN in providing care for a patient with a risk for increased ICP. What finding needs to be reported to the RN?

Shallow, even respirations

Narrowing pulse pressure

Increased systolic blood pressure

Pulse of 98

Answer and Explanation

The Correct Answer is B

A. Shallow, even respirations may be a normal finding or indicate respiratory distress, but it is not a specific sign of increased ICP. It should still be monitored, but it is not the most concerning finding in this scenario.

B. Narrowing pulse pressure, which is the difference between systolic and diastolic blood pressure, is a sign of increased intracranial pressure (ICP). As ICP rises, the body compensates by increasing systolic blood pressure and decreasing diastolic pressure, leading to a narrowing pulse pressure. This is a critical sign that should be reported immediately to the RN.

C. Increased systolic blood pressure is a compensatory mechanism to maintain cerebral perfusion when ICP increases. While it is concerning, it is not as immediately alarming as narrowing pulse pressure, which is a more direct indicator of increased ICP.

D. A pulse of 98 is within normal limits for most adults and does not indicate any immediate concern regarding increased ICP. It should be monitored, but it does not require urgent reporting to the RN.

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Correct Answer is A

Explanation

A. Attempt to determine what the client was looking for is the best response. In Alzheimer's disease, clients may exhibit wandering behavior and confusion, often seeking something familiar or trying to meet an unmet need. Understanding what the client was looking for can help address their needs and prevent further agitation.

B. Reprimanding the client for invading the other client's privacy is not appropriate. Clients with Alzheimer's disease may not be aware of the concept of privacy or the impact of their actions. Reprimanding can cause distress and confusion.

C. Explaining the client's Alzheimer's diagnosis to the frightened client may help provide understanding, but it does not address the immediate concern of calming the frightened client. The focus should be on managing the behavior in the moment.

D. Asking the client to apologize for his behavior is not appropriate, as the client may not have the cognitive ability to understand or remember the need to apologize. This could cause frustration and confusion.

A. Place the patient in isolation B. Assess the patient's pain level C. Pad the patient's bed rails D. Teach the patient what to expect with radiation treatments

Correct Answer is D

Explanation

A. Isolation is not typically required for a patient receiving radiation unless there is a specific infection concern. Radiation does not require isolation.

B. While assessing pain is important, the priority at this point is to ensure that the patient understands the treatment process and what to expect, which can help reduce anxiety and improve cooperation during treatment.

C. Padding the bed rails is typically done for patients at risk of seizures or injury. While this might be relevant for some patients with brain tumors, the immediate priority is to educate the patient about the treatment.

D. Teaching the patient what to expect with radiation treatments is the priority. This helps reduce anxiety, ensures informed consent, and prepares the patient for the treatment process. Education about side effects, the procedure, and the expected outcomes is crucial for managing the patient’s experience.

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The LPN/LVN is assisting the RN in providing care for a patient with a risk for increased ICP. What finding needs to be reported to the RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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