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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","B","C"]

Explanation

A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.

B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.

C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.

D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.

E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.

A. Blood alcohol level of 0.09% (19.5 mmol/L). B. Weight loss of 10 lb (4.5 kg) in past month. C. Six hours of sleep in the past three days. D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L).

Correct Answer is D

Explanation

A. Blood alcohol level of 0.09% (19.5 mmol/L): This alcohol level indicates mild intoxication. It can cause slurred speech and gait changes, but the effects are usually transient and less concerning than drug toxicity. It should be monitored, but is not as urgent as lithium toxicity.

B. Weight loss of 10 lb (4.5 kg) in past month: This degree of weight loss may suggest poor nutritional intake or a depressive episode, but it is not immediately life-threatening. It requires follow-up but does not explain the acute neurological signs the client is exhibiting.

C. Six hours of sleep in the past three days: Severe sleep deprivation can exacerbate mood instability in bipolar disorder, but it does not account for slurred speech or gait disturbances. This concern is significant for mental health management but not the priority in this situation.

D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L): This is above the therapeutic range and suggests lithium toxicity, which can cause neurological signs such as slurred speech and ataxia. Immediate reporting is crucial to prevent progression to more severe toxicity, including seizures or coma.

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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

The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]

Correct Answer is ["A","B","C"]

Explanation

Correct Answer is D

Explanation

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