A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Pupillary dilation
Decorticate posturing
Altered level of consciousness
Cheyne-Stokes respirations
The Correct Answer is C
Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Weight gain in a short period of time indicates fluid retention, which can worsen the client's condition and lead to complications such as pulmonary edema and hypertension. The nurse should report this finding to the provider and monitor the client's fluid balance and electrolytes.
Correct Answer is ["A","B","C"]
Explanation
Drinking plenty of fluids helps flush out bacteria from the urinary tract and prevent urinary stasis . Wiping from front to back prevents contamination of the urethra with fecal bacteria . Cranberry juice may prevent bacterial adherence to the bladder wall and lower the pH of urine, making it less favorable for bacterial growth . However, cranberry juice should be low in fructose because high-fructose corn syrup may increase bacterial growth . Bubble baths may irritate the urethra and increase the risk of infection . Voiding frequently (every 2 to 3 hours) prevents urinary stasis and bacterial growth .
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.