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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.

A. Urine output 45 mL/hr B. Potassium 5.2 mEq/L C. Capillary refill 1.5 seconds D. PaCO2 37 mm Hg

Correct Answer is B

Explanation

This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Correct Answer is B

Explanation

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