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 C

Explanation

Choice A reason: Inserting a padded tongue blade during a seizure is outdated and dangerous, as it can cause injury or obstruct the airway. Seizures involve uncontrolled neuronal firing, and forcing objects into the mouth risks trauma or aspiration, contrary to current epilepsy management guidelines focusing on airway protection and safety.

Choice B reason: Placing the client on their back during a seizure increases the risk of aspiration, as secretions or vomit may obstruct the airway. Seizures cause loss of motor control, and the side-lying position is preferred to maintain airway patency, making this an incorrect and unsafe instruction.

Choice C reason: Moving objects away from the client during a seizure is critical to prevent injury from uncontrolled movements caused by synchronized neuronal discharges in the brain. This ensures a safe environment, reducing the risk of trauma from striking objects, aligning with standard seizure management protocols to prioritize safety.

Choice D reason: Restraining a client during a seizure can cause injury, as forceful movements from epileptiform activity are involuntary. Restraints may increase muscle strain or fractures and heighten agitation, potentially worsening the seizure or causing psychological harm, making this an inappropriate and unsafe action.

A. Traumatic B. Anticipatory C. Complicated D. Disenfranchised

Correct Answer is B

Explanation

Choice A reason: Traumatic grief follows sudden, violent loss, not a terminal illness with expected death. The client’s situation involves forewarning, making anticipatory grief more fitting, so this is incorrect.

Choice B reason: Anticipatory grief occurs before an expected loss, as in terminal cancer, where clients and families prepare emotionally. This aligns with the situation, making it the correct type of grief.

Choice C reason: Complicated grief involves prolonged, impairing mourning after loss, not before. The client is still alive, so anticipatory grief is current, making this incorrect for the scenario.

Choice D reason: Disenfranchised grief is unacknowledged loss, like miscarriage. Terminal cancer is socially recognized, so anticipatory grief fits better, making this incorrect for the client’s experience.

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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:

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Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has cancer and is terminally ill. The nurse should recognize that the client and their family might be experiencing which of the following types of grief?

Correct Answer is B

Explanation

A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse take?

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A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief?

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

The nurse is caring for a 45-year-old male who arrives at the emergency department actively seizing for the past 10 minutes. Which of the following is the nurse’s priority action?

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