The practical nurse (PN) is monitoring the neurological vital signs of a client with a recently closed head injury. Which vital sign trends indicate increased intracranial pressure (ICP) and should be reported to the charge nurse?
Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension.
Bounding pulse rate, groaning respiratory effort, and elevated blood pressure.
Thready rapid pulse, trembling, perspiration, weakness, and irritability.
Bradycardia, irregular respiratory patterns, widening pulse pressure.
The Correct Answer is D
The vital sign trends that indicate increased intracranial pressure (ICP) and should be reported to the charge nurse are:
Bradycardia: A slow heart rate can be a sign of increased ICP.
Irregular respiratory patterns: Abnormal breathing patterns, such as irregular or Cheyne-Stokes respirations, can be indicative of increased ICP.
Widening pulse pressure: An increased difference between systolic and diastolic blood pressure (widening pulse pressure) can be a sign of increased ICP.
A- Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension: While an elevated heart rate and respiratory rate can be associated with increased ICP, hypotension (low blood pressure) is not typically seen in this condition. Hypotension can be a sign of other factors, such as hypovolemia or shock, which may or may not be related to the head injury.
B- Bounding pulse rate, groaning respiratory effort, and elevated blood pressure: Bounding pulse rate and elevated blood pressure are not specific to increased ICP. They can be influenced by other factors such as pain, anxiety, or medications. Groaning respiratory effort may indicate respiratory distress, but it is not directly related to increased ICP.
C- Thready rapid pulse, trembling, perspiration, weakness, and irritability: These signs and symptoms can be associated with various conditions such as anxiety, stress, or other physiological responses. While they may occur in the context of increased ICP, they are not specific to this condition alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Circumoral cyanosis, which is bluish discoloration around the mouth, can be a sign of inadequate oxygenation. It suggests that there may be an issue with the infant's respiratory or cardiovascular system, potentially indicating respiratory distress or a cardiac problem. Prompt assessment and intervention are necessary to determine the cause of the cyanosis and ensure the infant's well-being.
A. The six-hour-old infant with a large sacral "stork bite" refers to a common birthmark caused by dilated blood vessels. While it may be important to assess the birthmark and document its presence, it is not an urgent concern requiring immediate attention.
B. The two-day-old infant with a negative Ortolani's sign refers to a specific maneuver used to assess for developmental hip dysplasia or dislocation. A negative Ortolani sign indicates that there is no evidence of hip dislocation. While it is important to assess the infant's hips and document the findings, it does not require immediate attention.
D. The one-day-old infant with a positive Babinski's reflex refers to an abnormal response in which the infant's toes fan out and the big toe dorsiflexes when the sole of the foot is stimulated. While a positive Babinski's reflex can be a normal finding in infants under a certain age, it is important to assess the infant's neurological status. However, it does not require immediate attention compared to the infant with circumoral cyanosis, which indicates potential respiratory or cardiovascular distress.
Correct Answer is D, C, A, B
Explanation
- A 12-year-old child with a history of asthma is wheezing and complaining of shortness of breath. Wheezing and shortness of breath indicate respiratory distress, which can be a medical emergency for a child with asthma. Prompt intervention and assessment of the child's respiratory status are crucial.
- A 7-year-old child who has type 1 diabetes mellitus is experiencing extreme hunger and shakiness. These symptoms may indicate hypoglycemia, which requires immediate attention to prevent further complications. The PN should assess the child's blood glucose levels and provide appropriate treatment.
- A 10-year-old child with bleeding lacerations on both knees after falling on the playground. While bleeding lacerations require attention, they are not immediately life-threatening or likely to cause severe complications. However, the PN should still address this child's injuries promptly and provide appropriate wound care.
- A 5-year-old child is crying uncontrollably because of an incontinent bowel episode. While the child's distress is significant, it does not indicate an immediate life-threatening condition or urgent medical need. The PN should provide comfort, and reassurance, and assist with appropriate hygiene measures for the child.
Prioritizing care in this order ensures that the most urgent and potentially life-threatening conditions are addressed first, followed by those requiring immediate attention but with a lower risk of complications. Finally, the PN can attend to the client with a condition that, while distressing, is not immediately life-threatening or urgent.
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