The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?
Widening pulse pressure
Increasing restlessness
Decrease in the pulse rate
Dilated fixed pupils
The Correct Answer is B
A. A widening pulse pressure (the difference between systolic and diastolic blood pressure) can be a sign of increasing intracranial pressure (ICP), but it typically occurs later in the progression of ICP. Early signs of increased ICP are often more subtle and include changes in behavior and consciousness.
B. One of the earliest signs of increased ICP is altered mental status or behavioral changes, such as increasing restlessness or agitation. As pressure builds inside the skull, it affects the brain's ability to function normally, leading to these early signs. Restlessness may indicate that the brain is becoming less able to maintain normal function due to the increasing pressure.
C. A decrease in pulse rate may occur later in the course of increased ICP, particularly with severe increases in pressure. However, early signs typically involve changes in consciousness and mental status rather than changes in vital signs like heart rate.
D. Dilated and fixed pupils are a late sign of increased ICP and usually indicate significant brain herniation or severe neurological compromise. While they are serious and require immediate attention, they do not typically occur at the early stages of increased ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The first action should be to call the blood bank to report the mismatch in blood type. The patient is A positive, and the blood unit is AB negative, which is not compatible and could lead to a serious transfusion reaction. The blood bank can provide the correct unit of blood.
B. Initiating the transfusion with the wrong blood type is dangerous and could cause a life-threatening reaction.
C. Taking and recording vital signs is important but should only occur after confirming the correct blood product. Starting a transfusion with the wrong blood is a safety hazard.
D. While notifying the physician is important, the immediate action is to contact the blood bank to resolve the blood type mismatch.
Correct Answer is ["0.4"]
Explanation
Step 1: Desired dose = 2 mg
Step 2: Available concentration = 5 mg/mL
Step 3: Use the formula:
Volume to administer = Desired dose ÷ Concentration available
Step 4: Plug in the values:
Volume to administer = 2 mg ÷ 5 mg/mL = 0.4 mL
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