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 C
Explanation
A. Administration of norepinephrine IV push: Norepinephrine is a vasopressor used to treat hypotension in shock, but it does not address the underlying cause of an antigen-antibody reaction. It may be used if hypotension persists after epinephrine, but it is not the first-line treatment. Immediate reversal of the allergic response is more critical.
B. Administration of phosphodiesterase inhibitors: Phosphodiesterase inhibitors improve cardiac contractility and reduce afterload but are not indicated for anaphylactic shock. They do not counteract the systemic effects of a severe antigen-antibody reaction.
C. Administration of epinephrine: Epinephrine is the first-line treatment for anaphylactic shock caused by antigen-antibody reactions. It rapidly reverses vasodilation, bronchodilates, and stabilizes mast cells. Prompt IV or intramuscular administration is essential to prevent cardiovascular collapse and respiratory compromise.
D. Administration of antibiotics: Antibiotics are not indicated unless an infection is the trigger for shock. In antigen-antibody–mediated (anaphylactic) shock, the priority is reversing the allergic reaction. Antibiotics do not address vasodilation, bronchospasm, or histamine-mediated effects.
Correct Answer is D
Explanation
A. During waking hours for 2 to 3 months after the injury: Wearing the garment only while awake provides insufficient pressure to control hypertrophic scarring. These garments require near-continuous wear for many months to achieve adequate collagen remodeling.
B. 4 to 6 hours a day for 6 months: This amount of daily use is far too limited to influence scar tissue formation. Pressure therapy must be applied almost continuously to keep collagen fibers flattened and prevent thick, raised scars.
C. Only at night while sleeping for a year after the injury: Night-only wear does not maintain the necessary constant pressure needed for optimal scar management. Scar tissue forms throughout the day, and removal for long hours reduces therapeutic effect.
D. Continuously: Elastic pressure garments are typically worn 23 hours per day for many months to control hypertrophic scarring. Continuous pressure supports proper collagen alignment and reduces scar thickness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.