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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

0800: Heart rate 130 beats/minute, blood pressure 190/90 mm Hg; 1200: heart rate 136 beats/minute, blood pressure 200/100 mm Hg, Kussmaul respirations.

0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations.

0800: Heart rate 110 beats/minute, blood pressure 130/70 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 110/70 mm Hg, shallow respirations.

0800: Heart rate 70 beats/minute, blood pressure 120/60 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 90/60 mm Hg, rapid respirations.

Answer and Explanation

The Correct Answer is B

A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.

B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.

C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.

D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.

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Correct Answer is A

Explanation

A. Provide a bedside commode for toileting: This intervention helps reduce the cardiac workload by minimizing the effort needed for the client to walk to the bathroom. It allows the client to conserve energy and reduce the strain on the heart.

B. Assist with ambulation in the hallway: While mobility is important, ambulating in the hallway can increase the heart’s workload, especially in a client with heart failure and pneumonia. It's best to minimize unnecessary physical exertion to prevent exacerbations.

C. Teach to sleep in a side-lying position: While side-lying can sometimes help with breathing, this position does not directly reduce the cardiac workload. The priority is ensuring the client has adequate rest and minimizing physical strain.

D. Encourage active range of motion exercises: While range of motion exercises are important for preventing complications like muscle atrophy, they may increase the cardiac workload. For a client with pneumonia and heart failure, the priority is to reduce exertion and conserve energy.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Rationale for Correct Choices:

Impaired physical mobility: Rheumatoid arthritis leads to joint inflammation, stiffness, and potential deformities. These symptoms may result in decreased range of motion and difficulty with physical movements, contributing to impaired mobility.
Acute pain: RA causes acute inflammation in the joints, resulting in pain, especially during flare-ups. The client experiences pain and stiffness in the hands and wrists, which aligns with the acute pain risk associated with RA.
Knowledge deficit: Newly diagnosed RA patients often lack understanding about the disease process, treatment options, and lifestyle modifications. The nurse needs to recognize that the client requires education to manage their condition effectively and understand the long-term implications.

Rationale for Incorrect Choices:

Electrolyte imbalance: Electrolyte imbalances are not a typical complication of rheumatoid arthritis. While certain medications used to treat RA (like corticosteroids) can impact electrolyte levels, this is not an immediate concern or a direct risk associated with RA itself.

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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to addressdropdown. In addition, he will need interventions to preventdropdown.

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Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.