When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

Continue the assessment because no actions are indicated at this time.

Document the reading because it reflects that the treatment has been effective.

Contact the health care provider to review the care plan.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

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Correct Answer is ["D","E"]

Explanation

Choice A rationale

Exercise is important but should be done in a well-lit, comfortable environment. Exercising in a dark room is not specifically beneficial for migraine management and may not address trigger factors effectively.

Choice B rationale

Adequate sleep is crucial for migraine management. Advising to sleep no more than 5 hours at a time is incorrect; sufficient rest is necessary to prevent migraines.

Choice C rationale

St. John's Wort is commonly used for depression and anxiety but has no proven efficacy for migraine management. It may also interact with other medications.

Choice D rationale

Keeping a food diary helps identify dietary triggers that can lead to migraines. Tracking food intake can reveal patterns and specific triggers to avoid.

Choice E rationale

Maintaining a headache diary is important for tracking migraine frequency, duration, and potential triggers. It helps in managing and understanding the condition better.

A. Dysfunction in the cerebrum. B. Dysfunction in the brain stem. C. Dysfunction in the spinal column. D. Dysfunction in the motor cortex.

Correct Answer is B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

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When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session?

Correct Answer is ["D","E"]

Explanation

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is B

Explanation

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