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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. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.

B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.

C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.

D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.

A. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is B

Explanation

A. While the presence of greenish fluid in a nasogastric tube can indicate a small bowel obstruction, this finding alone does not necessarily indicate an immediate life-threatening condition. The client should be monitored, but this is not the priority.

B. Abdominal rigidity in the context of a volvulus (twisting of the bowel) can indicate bowel ischemia or perforation, which is a surgical emergency. Immediate intervention is needed to prevent further complications such as sepsis or peritonitis.

C. A paralytic ileus is a common postoperative complication and often resolves with time. While the absence of bowel sounds is concerning, it is a routine finding in this situation and does not require immediate attention unless there are signs of further complications.

D. Abdominal distention in a large bowel obstruction can indicate a need for further assessment and treatment. However, compared to a volvulus with abdominal rigidity, this situation is less urgent and does not represent an immediate life-threatening emergency.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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