A client has a head injury and is brought to the emergency department. The vital signs are P: 78; R: 16; B/P: 120/80. The change in this client’s vital signs that indicates increasing intracranial pressure (ICP) requiring notification of the practitioner is:

P: 50; R: 22; B/P: 140/60

P: 56; R: 20; B/P: 130/110

P: 60; R: 18; B/P: 126/96

P: 120; R: 16; B/P: 80/60

Answer and Explanation

The Correct Answer is A

Choice A reason: Increasing ICP causes Cushing’s triad: bradycardia (P: 50), irregular respirations (R: 22), and widened pulse pressure (B/P: 140/60). These indicate brain compression, requiring immediate notification, making this the correct vital sign change.

Choice B reason: A pulse of 56 and B/P of 130/110 show hypertension but not widened pulse pressure. Respirations are mildly elevated, not irregular, making this less indicative of ICP than Cushing’s triad.

Choice C reason: P: 60, R: 18, and B/P: 126/96 are near normal, not reflecting Cushing’s triad. These changes are subtle and less concerning for acute ICP elevation, making this incorrect.

Choice D reason: P: 120 and B/P: 80/60 suggest shock, not ICP. Tachycardia and hypotension are opposite to Cushing’s triad, making this incorrect for indicating increasing intracranial pressure.

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Correct Answer is B

Explanation

Choice A reason: Having the client touch their nose with eyes closed tests cerebellar function and proprioception, not the oculomotor nerve (cranial nerve III). This assesses coordination and sensory integration, unrelated to the nerve controlling eye movement and pupil response, making it an incorrect choice.

Choice B reason: Instructing the client to look up and down without moving their head tests the oculomotor nerve (cranial nerve III), which innervates most extraocular muscles and controls pupil constriction. This movement relies on nerve function for vertical eye motion, making it the correct assessment for oculomotor nerve integrity.

Choice C reason: Shrugging shoulders against resistance tests the spinal accessory nerve (cranial nerve XI), which innervates the trapezius muscle. This is unrelated to the oculomotor nerve, which governs eye movement and pupil response, so this action does not assess cranial nerve III function.

Choice D reason: Observing smiling and frowning tests the facial nerve (cranial nerve VII), which controls facial muscles. This is distinct from the oculomotor nerve, which manages eye movements and pupil constriction, making it an inappropriate method for assessing cranial nerve III function.

A. Rationalization B. Projection C. Repression D. Regression

Correct Answer is B

Explanation

Choice A reason: Rationalization involves justifying behavior with logical excuses, not blaming others. The client attributes their failure to their partner, which is projection, making this incorrect for the defense mechanism.

Choice B reason: Projection involves attributing one’s own shortcomings, like forgetting medication, to another person, such as the partner. The client blames their partner, making this the correct defense mechanism.

Choice C reason: Repression is unconsciously blocking distressing thoughts, not blaming others. The client openly acknowledges the missed medication, so this is incorrect for the observed behavior.

Choice D reason: Regression involves reverting to childish behaviors, not blaming others. The client’s statement reflects externalizing responsibility, fitting projection, making this incorrect for the defense mechanism.

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A client has a head injury and is brought to the emergency department. The vital signs are P: 78; R: 16; B/P: 120/80. The change in this client’s vital signs that indicates increasing intracranial pressure (ICP) requiring notification of the practitioner is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of the oculomotor cranial nerve?

Correct Answer is B

Explanation

A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Correct Answer is B

Explanation

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The nurse is caring for the following clients. Which client would the nurse assess first after receiving shift report?

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

A nurse is caring for a client who is diagnosed with schizophrenia. Which of the following manifestations should the nurse identify as a negative symptom?

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?