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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 B

Explanation

A. Hold the client at arm's length while transferring to better distribute the body weight: Holding the client at arm's length is not recommended as it does not provide adequate support. The caregiver should be close to the client to maintain control to ensure safe transfer.

B. Place the client's locked wheelchair on the client's strong side next to the bed: Positioning the wheelchair on the client’s strong side provides support and stability during the transfer, allowing the caregiver to assist effectively while ensuring the client’s safety.

C. Pull the client into position by reaching from the opposite side of the bed: Reaching from the opposite side of the bed can cause strain on the caregiver's back and may increase the risk of injury. It is safer to stay close to the client during transfers to minimize physical strain.

D. Apply a gait belt around the client's waist once a standing position has been assumed: The gait belt should be applied before the client assumes a standing position. This ensures proper support and control during the transfer. Waiting until standing could cause instability.

A. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L) B. The client dilates quickly to 10 cm and feels a strong urge to push C. The fetal heart rate is reassuring with a baseline of 145 and moderate variability D. After three cycles of open-glottis pushing, the baby's head is crowning E. The head is born easily over an intact perineum F. The infant weighs 9 lbs. 9 oz (4.34 kgs) G. Apgar of 7 at 1 minute, then 9 at 5 minutes

Correct Answer is ["A","B","C","D","E","G"]

Explanation

Rationale for Correct Findings:

The client dilates quickly to 10 cm and feels a strong urge to push: Rapid dilation and the strong urge to push indicate that the client is progressing effectively through labor, with no signs of obstruction or delays.
The fetal heart rate is reassuring with a baseline of 145 and moderate variability: A reassuring fetal heart rate with moderate variability is a good sign that the baby is not experiencing any distress during labor, indicating a healthy fetal condition.
The head is born easily over an intact perineum: The ease of the baby's head being born over an intact perineum suggests that the delivery is progressing smoothly, with minimal risk of perineal trauma.
Apgar of 7 at 1 minute, then 9 at 5 minutes: The Apgar scores of 7 at 1 minute and 9 at 5 minutes show a positive outcome in neonatal assessment, with a good recovery.
The fasting blood glucose (FSBG) is 86 (4.8 mmol/L): A fasting blood glucose of 86 mg/dL is within the normal range (74 to 106 mg/dL), indicating that the client’s blood glucose levels are well-controlled, which is a positive sign for managing her gestational diabetes.

Rationale for Negative Finding:

The infant weighs 9 lbs. 9 oz (4.34 kgs): Macrosomia (a term used for babies born weighing more than 4 kg) can be associated with gestational diabetes, which increases the likelihood of delivering a larger baby. Macrosomia may lead to potential complications such as shoulder dystocia or increased risk for cesarean delivery.

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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 demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D","E","G"]

Explanation

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