A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

Blood pressure 110/72 mm Hg

Intracranial pressure (ICP) 25 mm Hg

PaC02 35 mm Hg

Pulse oximetry 96%

Answer and Explanation

The Correct Answer is B

A. Blood pressure 110/72 mm Hg: A blood pressure of 110/72 mm Hg is within the normal range and does not require intervention. Maintaining a stable blood pressure is essential after a craniotomy, and this reading indicates no immediate concerns.

B. Intracranial pressure (ICP) 25 mm Hg: An ICP of 25 mm Hg is above the normal range (typically 5-15 mm Hg). Elevated ICP can lead to brain herniation and other severe complications. The nurse should notify the healthcare provider immediately and take measures to reduce ICP, such as positioning and administering medications if needed.

C. PaCO2 35 mm Hg: A PaCO2 of 35 mm Hg is within the normal range (35-45 mm Hg). The normal level of carbon dioxide is important for maintaining appropriate cerebral perfusion pressure, and this value does not indicate a problem.

D. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range (95-100%) and indicates adequate oxygenation. No immediate intervention is needed unless the value drops significantly below this level.

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Correct Answer is D

Explanation

A. Flaccidity: Flaccidity implies a complete lack of muscle tone and limpness. The patient in the image exhibits rigidity and specific posturing, which is the opposite of flaccidity.

B. Rigidity in the upper extremities: While there is rigidity, this option doesn't capture the specific pattern of posturing. The rigidity is part of a distinct decorticate pattern involving both upper and lower extremities in a specific way.

C. Decerebrate posturing: Decerebrate posturing is characterized by rigid extension of all four limbs, with pronation of the forearms. The image clearly shows flexion of the arms, which is the defining characteristic of decorticate posturing.

D. Decorticate posturing: The posture depicted in the image, with the arms flexed at the elbows and wrists and held close to the body, while the legs are extended, is the hallmark of decorticate posturing. This indicates severe brain injury above the level of the midbrain.

A. Insert a padded tongue blade into the client's mouth. B. Place a pillow under the client's head C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration

Correct Answer is B

Explanation

A. Insert a padded tongue blade into the client's mouth: Inserting a tongue blade can cause harm, such as damaging the client's teeth or mouth or causing them to bite down on the blade, leading to injury. It is not recommended during a seizure.

B. Place a pillow under the client's head: Placing a pillow under the client’s head helps protect it from injury during the clonic phase of a seizure. This is the most appropriate and safest action to prevent head trauma while the client is experiencing a seizure.

C. Gently restrain the client's extremities: Restraint during a seizure can lead to injury and should be avoided. The priority is to allow the seizure to occur without interference, ensuring the client’s safety by preventing injury from the environment.

D. Apply a face mask for oxygen administration: Oxygen may be indicated if the client shows signs of respiratory distress, but applying a face mask immediately is not the priority. Ensuring safety during the seizure (e.g., protecting the head) is more important in the initial response.

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A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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