A client admitted with a head injury has admission vital signs of temperature 98.6 F (37 C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken several hours after admission, will be of the most concern to the nurse?
Blood pressure 148/78, pulse 112, respirations 28.
Blood pressure 156/60, pulse 58, respirations 12
Blood pressure 130/72, pulse 90, respirations 32.
Blood pressure 110/70, pulse 120, respirations 30.
The Correct Answer is B
A. Blood pressure 148/78, pulse 112, respirations 28: Mild increases in blood pressure, pulse, and respirations can be compensatory responses to stress or pain. These changes are concerning but not immediately indicative of life-threatening complications.
B. Blood pressure 156/60, pulse 58, respirations 12: This pattern represents Cushing’s triad—hypertension with widened pulse pressure, bradycardia, and irregular respirations—indicating increased intracranial pressure. It is a neurologic emergency requiring immediate intervention to prevent brain herniation.
C. Blood pressure 130/72, pulse 90, respirations 32: Slightly increased respirations with stable blood pressure and pulse are not as alarming. They may reflect pain, anxiety, or mild hypoxia but are not emergent signs of intracranial pressure elevation.
D. Blood pressure 110/70, pulse 120, respirations 30: This pattern suggests early compensation for hypovolemia or stress. While it requires monitoring, it does not indicate imminent neurologic deterioration like Cushing’s triad.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Perform a halo test: Clear nasal drainage in a client with periorbital ecchymosis may indicate cerebrospinal fluid (CSF) leakage. The halo or ring test helps differentiate CSF from normal nasal secretions, which is critical for detecting a basilar skull fracture. Early identification guides further neurologic assessment and prevents complications.
B. Instruct the client to blow his nose and check the nares for inflammation: Blowing the nose can increase intracranial pressure and worsen CSF leakage. Assessing for inflammation does not confirm CSF presence and may be harmful in suspected skull fractures.
C. Obtain a specimen of the fluid for culture and sensitivity: Culturing the fluid is unnecessary initially and may delay urgent assessment. Identifying CSF leakage takes priority to prevent infection and guide immediate care.
D. Check the nasal drainage for glucose: Glucose testing can suggest CSF, but the halo test provides a more rapid and reliable bedside assessment. Confirming CSF leakage quickly is essential for early intervention.
Correct Answer is D
Explanation
A. release of epinephrine leading to massive vasodilation of spinal cord vessels: Secondary SCI involves ischemia and inflammation rather than vasodilation caused by epinephrine. Excess catecholamines may contribute to vasoconstriction and further injury, not vasodilation.
B. initial infarction of the white matter of the cord: Infarction can occur, but it is a consequence of secondary injury rather than the initial event. The primary insult triggers processes like hemorrhage, edema, and inflammation, which lead to tissue necrosis. Infarction is part of the progression, not the starting mechanism.
C. mechanical transection of the cord: Mechanical transection describes the primary injury from trauma, such as a laceration or fracture, not secondary injury. Secondary SCI develops from biochemical and cellular responses after the initial trauma.
D. necrotic destruction of the cord from hemorrhage and edema: Secondary SCI is characterized by tissue necrosis resulting from hemorrhage, edema, ischemia, and inflammatory processes following the primary injury. These mechanisms expand the area of injury beyond the initial trauma.
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