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. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.

B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.

C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.

D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.

A. Intracranial pressure B. Respiratory status C. Temperature D. Serum electrolytes

Correct Answer is B

Explanation

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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