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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Unable to discriminate words and letters is associated with left hemisphere damage, which is more linked to language and communication deficits.
B. Deficits in the right visual field would typically occur with left hemisphere damage, which affects vision.
C. Motor retardation is more often associated with left hemisphere damage affecting motor control.
D. Right cerebral hemisphere damage often results in behavioral changes, such as poor impulse control, lack of awareness of deficits (anosognosia), and changes in emotional responses.

A. Encourage frequent ambulation B. Maintain foot in a dependent position. C. Apply warm, moist heat D. Wrap the foot snugly in the blanket

Correct Answer is C

Explanation

A. Ambulation may worsen the condition as it could increase swelling or spread infection.
B. This may increase swelling and should generally be avoided in cellulitis.
C. This helps to improve circulation and reduce swelling in cellulitis.
D. Wrapping the foot tightly could exacerbate swelling and discomfort.

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Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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