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 A

Explanation

A. Ventriculostomy is considered the gold standard for measuring intracranial pressure (ICP). This procedure involves placing a catheter into the brain's ventricles to directly measure the pressure inside the skull.
B. Fiberoptic catheter can also be used for ICP measurement, but ventriculostomy is more accurate and allows for drainage of cerebrospinal fluid if needed.
C. Central line is used for venous access, not for measuring ICP.
D. Transcranial Doppler is used to assess blood flow in the brain, but not for direct ICP measurement.

A. Reduce edema of the brain. B. Increase cell size in the brain. C. Provide fluid hydration. D. Expand extracellular fluid volume.

Correct Answer is A

Explanation

A. Osmotic diuretics, such as mannitol, help reduce cerebral edema by drawing fluid out of the brain.
B. Osmotic diuretics do not increase cell size.
C. The goal of osmotic diuretics is not to provide fluid hydration.
D. The medication does not expand extracellular fluid volume; it reduces it.

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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

Which method of measurement is the gold standard for obtaining intracranial pressures?

Correct Answer is A

Explanation

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Correct Answer is A

Explanation

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