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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While the liver is centrally located and plays a significant role in filtering blood, its location alone does not directly explain why it's a common site for metastasis.
B. Portal hypertension refers to increased pressure within the portal vein system, usually due to liver disease, not metastasis.
C. The liver has a dual blood supply from the portal vein and the hepatic artery, which makes it a key organ for filtering blood coming from the digestive tract. This provides a route for cancer cells from the gastrointestinal tract and other organs to travel to the liver, making it a common site for metastasis.
D. Tumor markers are substances that may be found in higher amounts in the blood or tissues of people with cancer. However, they do not directly explain why the liver is a common site for metastasis.

A. Encourage the client to take deep breaths B. Administer naloxone 0.4 mg SQ and reassess C. Check the temperature and apply warmed blankets D. Call rapid response for more assistance

Correct Answer is A

Explanation

A. Hypoxia is common after surgery due to the effects of anesthesia and the client being in a supine position. A pulse oximetry reading of 88% indicates mild hypoxia. The first step in managing this is to encourage deep breathing or to have the patient use an incentive spirometer to improve ventilation and oxygenation. This is a non-invasive method that can help increase oxygen levels and prevent complications like atelectasis (lung collapse).

B. While opioid overdose can cause respiratory depression, there is no indication that the client is showing signs of opioid toxicity (e.g., unresponsiveness, slow/shallow breathing). The client is sleepy but easily arousable, suggesting that the sleepiness is related to the residual effects of anesthesia rather than opioid overdose. Administering naloxone is not indicated unless there are signs of severe respiratory depression or unresponsiveness, which is not the case here.

C. While postoperative hypothermia can occur, it is unlikely to cause oxygen saturation to drop to 88%. The priority action should be to improve the client's oxygenation first, as that is more immediately critical in this scenario.

D. The client's oxygen saturation of 88% is concerning, but it is manageable with initial interventions such as encouraging deep breathing. Calling a rapid response team would be appropriate if the patient's condition worsens or doesn't improve with initial interventions.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse knows that the liver is a common site for metastasis from other primary cancers due to:

Correct Answer is C

Explanation

The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy, but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Correct Answer is A

Explanation

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