A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Cheyne-Stokes respirations
Pupillary dilation
Altered level of consciousness
Decorticate posturing
The Correct Answer is C
Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.
Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.
Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.
Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
Correct Answer is D
Explanation
Choice A reason: Applying antibiotic ointment to the lesions is not recommended for the treatment of genital herpes, which is caused by a virus, not bacteria. Antiviral medications are the appropriate treatment for managing herpes outbreaks.
Choice B reason: Natural skin condoms are not effective in preventing the transmission of genital herpes because the virus can pass through the natural membrane. The use of latex or polyurethane condoms is recommended as they are more effective in reducing the risk of transmission.
Choice C reason: Expecting lesions to resolve in 6 weeks may not be accurate as the duration of a herpes outbreak can vary. Most herpes lesions tend to resolve within 2 to 4 weeks. However, the virus remains in the body and can cause recurrent outbreaks.
Choice D reason: The duration of medication for genital herpes depends on whether the treatment is for an initial outbreak, chronic suppression, or episodic therapy. For an initial outbreak, antiviral medication is typically taken for 7 to 10 days. For chronic suppression, medication might be taken daily for an extended period to prevent or reduce the frequency of outbreaks.
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