Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?
Increased ICP
Decreased cerebral blood flow (CBF)
Increased cerebral perfusion pressure (CPP)
Normal intracranial pressure
The Correct Answer is B
A. Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B. Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C. Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D. Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B. Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C. Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D. Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.
Correct Answer is C
Explanation
A. "Wear compression stockings daily." is not specifically related to preventing diabetic complications of the eyes and kidneys.
B. "Examine your feet carefully every day." is important for preventing diabetic foot ulcers but is not directly related to preventing retinopathy and nephropathy.
C. Maintaining stable blood glucose levels is the most effective way to prevent complications like retinopathy and nephropathy in clients with diabetes mellitus. Consistently high blood glucose levels can lead to damage to blood vessels in the eyes and kidneys.
D. "Have an eye examination once per year." is important, but maintaining stable blood glucose levels is the most effective long-term prevention strategy.
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