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. The postictal phase refers to the period immediately following a seizure when the client is often drowsy, confused, or difficult to arouse. This phase can last for several minutes to hours, depending on the individual.

B. Absence seizures are brief, generalized seizures characterized by staring and loss of awareness, often without a postictal phase.

C. The aura phase refers to the sensory warning or symptoms that precede a seizure, not the post-seizure state.

D. Automatisms are involuntary, repetitive movements (such as lip smacking or hand wringing) that can occur during a seizure, but they do not describe the postictal state.

A. Radiating pain down the leg B. Headache C. Difficulty breathing D. Blurred vision

Correct Answer is A

Explanation

A. A lumbar herniated disc commonly causes radiating pain down the leg, known as sciatica. This occurs when the herniated disc compresses a nerve root, often causing pain, numbness, tingling, or weakness that radiates down the leg.

B. Headache is not a typical symptom of a lumbar herniated disc. Headaches are generally associated with conditions affecting the head or neck, not the lower back.

C. Difficulty breathing is not associated with a lumbar herniated disc. Breathing problems are typically related to respiratory or cardiac conditions, not issues with the spine.

D. Blurred vision is not a symptom of a lumbar herniated disc. Vision changes are more often related to eye or neurological issues affecting the brain, not the lower back.

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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

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