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 A
Explanation
A. Decreasing environmental stimuli can help reduce the risk of seizures and further stress on the patient. This is especially important in cases of meningitis, as the patient may be more sensitive to light, sound, and touch.
B. A vascular assessment is important but not the next immediate action in this scenario.
C. Administering an antipyretic is important but not the priority action right after implementing droplet precautions.
D. Assessing cranial nerves may be necessary later in the assessment but is not the immediate next step.
Correct Answer is B
Explanation
A. Strabismus refers to misalignment of the eyes, not an infection.
B. A hordeolum, also known as a stye, is an infection of a sebaceous gland, presenting as a painful, red nodule near the eyelid margin.
C. Blepharitis refers to inflammation of the eyelid and would present with redness or flaking, not a white nodule.
D. Conjunctivitis is inflammation of the conjunctiva, not an infection of a sebaceous gland.
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