When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min

BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min

BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Answer and Explanation

The Correct Answer is D

A.   BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B.   BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C.   BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D.   The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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Correct Answer is C

Explanation

A. Nicardipine is a calcium channel blocker used for blood pressure management, not for decreasing ICP.
B. Dopamine is used for shock or hypotension but does not address ICP.
C. Mannitol is an osmotic diuretic used to decrease ICP by drawing fluid out of the brain and reducing swelling.
D. Phenytoin is an anticonvulsant used to prevent seizures, but it does not directly affect ICP.

A. Oriented to person, place, and year B. Bradycardia C. Blurred vision D. Severe headache

Correct Answer is D

Explanation

A. Orientation to person, place, and time is not expected in meningitis as the infection typically causes altered mental status.
B. Bradycardia is not a typical finding in meningitis. Increased intracranial pressure may lead to tachycardia, not bradycardia.
C. Blurred vision can occur with increased ICP or certain infections, but it is not a primary symptom of meningitis.
D. Severe headache is a hallmark symptom of meningitis, due to inflammation of the meninges, causing pain and increased intracranial pressure.

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse admits a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse expect to administer to decrease ICP?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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