The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

BP 190/84, HR 50, and an irregular respiratory pattern

BP 190/84, HR 150, and an irregular respiratory pattern

BP 80/50, HR 50, and Kussmaul respirations

BP 80/50, HR 150, and Cheyne-Stokes respirations

Answer and Explanation

The Correct Answer is A

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

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Correct Answer is A

Explanation

A. Patient has slight elevations in liver function test results: Phenytoin is primarily metabolized by the liver, and elevated liver function tests may indicate impaired liver function, potentially affecting the metabolism and clearance of phenytoin. Consultation with the healthcare provider is warranted to assess the risk-benefit ratio of administering phenytoin in the presence of liver function abnormalities.

B. Patient's most recent blood pressure is 156/92 mm Hg: While hypertension is not a contraindication for phenytoin administration, it is important to monitor blood pressure, especially considering the potential cardiovascular side effects of the medication. However, elevated blood pressure alone does not typically warrant consultation before administering phenytoin.

C. Patient experiences an aura before seizures: Experiencing an aura before seizures is a common phenomenon in patients with epilepsy and does not necessarily contraindicate the use of phenytoin. In fact, phenytoin is commonly prescribed to prevent seizures, including those preceded by an aura.

D. Patient has tonic-clonic seizures: Phenytoin is indicated for the treatment and prevention of tonic-clonic seizures, among other seizure types. Therefore, the presence of tonic-clonic seizures would not typically warrant consultation before administering phenytoin.

A. Send the patient for a computed tomography (CT) scan. B. Check the respiratory rate and effort. C. Assess the Glasgow Coma Scale score. D. Take the patient's blood pressure.

Correct Answer is B

Explanation

A. Send the patient for a computed tomography (CT) scan: While obtaining a CT scan is important for diagnosing potential causes of the patient's left-sided hemiparesis, assessing the patient's respiratory status takes precedence to ensure adequate oxygenation and ventilation.

B. Check the respiratory rate and effort: Assessing the patient's respiratory rate and effort is the first priority to identify any signs of respiratory distress or compromise. Adequate oxygenation and ventilation are essential for maintaining vital organ function.

C. Assess the Glasgow Coma Scale score: While assessing the Glasgow Coma Scale score is important for evaluating the patient's level of consciousness and neurological status, it is not the first action to take in a patient with potential respiratory compromise.

D. Take the patient's blood pressure: While obtaining the patient's blood pressure is important for assessing hemodynamic stability, it is not the first priority when the patient presents with left-sided hemiparesis and may be at risk for respiratory compromise.

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The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

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